New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian
Billing Information Is The Billing Address the Same?
TitleFirstLastMISuffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical History

Referred By:
Referring Doctor:
Any family members patients here? Who?:
Hobbies:
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of CLs worn in past:
Do you have back up glasses for your contacts?
Primary Vision Correction:
Sunglasses?
Interested in Laser Vision Correction?
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
Eye Meds:
Last Eye Doctor:
Primary Care Physician:
Systemic Meds:
Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+
Family Med History:
Family Eye History:
Medication and Seasonal Allergies:
NOTES/SOCIAL HISTORY

Review of Systems


DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

General:     Ears, Nose, Throat:     Cardiovascular: 


Respiratory:     Genital, Kidney, Bladder:     Muscles, Bones, Joints: 


Skin:     Neurological:     Psychiatric: 


Endocrine:   :  Blood/Lymph:     Allergic/Immunologic: 

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