New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Miss

Address:
City:		State/ZipCode	WI IL IN IA MN MI

Home Phone:		Work Phone:
Other Phone:		Alerts:
Cell Phone:		Preferred Contact Method:	Home Phone Work Phone Cell Phone Other Phone Text Message Email
SSN		Email
Birthday		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Winter, Christopher	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev. Miss

Address

City	State	ZipCode
	WI IL IN IA MN MI

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None Advantra Freedom Aetna US Healthcare AHC American Medical Security Ameritas Anthem BCBS Medicare ANTHEM BLUE CROSS BLUE SHIELD Bankers Life & Casuality Blue Cross / Blue Shield Carpenters Health Fund CIGNA Claims Management Services, Ins Conneticut General Conseco Constitution Life Construction Workers Corestar DMERC B/Administar EBC ECI Health and Welfare Plan Employee Benefit Management Corp Employers Health Eye Care of Wisconsin Eye Care Plan Of America - Region 1 EyeMed Eyemed Discount Program Farmers Insurance Group First Health Network Fiserv Health Gallagher Bassett Service General American Golden Rule Great West Healthcare Gtl H.e.p. Administrators, Inc HCN Healtheos By Multiplan Healthpartners Humana Humana Gold/EyeMed Disc Insurtec John Alden Health Mason 8 Health Fund Medical Eye Services Medicare Medicare Complete Midwest Security Administrators Milwaukee Carpenters Health Fund Milwaukee Painters Local 781 Mutual of Omaha National Vision Administrators New Insurance none-no insurance coverage Operating Engineers Optum OTHER P5 Health services Inc. Physicians Plus Plumbers Local 75 Health Fund Principal Financial QuadMed Railroad Retirement Board Sample Insurance With Fee Table Sample Insurance With Plans & Fee Table Schenk SC Secure Horizons Sentry Life Sisco-Self Insured Services company State Farm Superior Vision Plan Time Insurance Company Tricare Trilogy Trustmark UMR United Health Allies Discount United Health Care United Teachers Associates Village of Sussex Vision care of Tampa Vision Insurance Plan of America Vision Service Plan Visioncare Plan Washington National Ins/Conseco Wausau WEA West Bend Mutual Insurance Company WI Sheet Metal Workers Health Fund Wisconsin Laborers Wisconsin Mason's Health Fund Wisconsin Pipe Trades Health Fund Wisconsin Ufcw Unions & employees Workman's Compensation WPPN/MULTIPLAN Wps
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:	None Advantra Freedom Aetna US Healthcare AHC American Medical Security Ameritas Anthem BCBS Medicare ANTHEM BLUE CROSS BLUE SHIELD Bankers Life & Casuality Blue Cross / Blue Shield Carpenters Health Fund CIGNA Claims Management Services, Ins Conneticut General Conseco Constitution Life Construction Workers Corestar DMERC B/Administar EBC ECI Health and Welfare Plan Employee Benefit Management Corp Employers Health Eye Care of Wisconsin Eye Care Plan Of America - Region 1 EyeMed Eyemed Discount Program Farmers Insurance Group First Health Network Fiserv Health Gallagher Bassett Service General American Golden Rule Great West Healthcare Gtl H.e.p. Administrators, Inc HCN Healtheos By Multiplan Healthpartners Humana Humana Gold/EyeMed Disc Insurtec John Alden Health Mason 8 Health Fund Medical Eye Services Medicare Medicare Complete Midwest Security Administrators Milwaukee Carpenters Health Fund Milwaukee Painters Local 781 Mutual of Omaha National Vision Administrators New Insurance none-no insurance coverage Operating Engineers Optum OTHER P5 Health services Inc. Physicians Plus Plumbers Local 75 Health Fund Principal Financial QuadMed Railroad Retirement Board Sample Insurance With Fee Table Sample Insurance With Plans & Fee Table Schenk SC Secure Horizons Sentry Life Sisco-Self Insured Services company State Farm Superior Vision Plan Time Insurance Company Tricare Trilogy Trustmark UMR United Health Allies Discount United Health Care United Teachers Associates Village of Sussex Vision care of Tampa Vision Insurance Plan of America Vision Service Plan Visioncare Plan Washington National Ins/Conseco Wausau WEA West Bend Mutual Insurance Company WI Sheet Metal Workers Health Fund Wisconsin Laborers Wisconsin Mason's Health Fund Wisconsin Pipe Trades Health Fund Wisconsin Ufcw Unions & employees Workman's Compensation WPPN/MULTIPLAN Wps
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:	None Advantra Freedom Aetna US Healthcare AHC American Medical Security Ameritas Anthem BCBS Medicare ANTHEM BLUE CROSS BLUE SHIELD Bankers Life & Casuality Blue Cross / Blue Shield Carpenters Health Fund CIGNA Claims Management Services, Ins Conneticut General Conseco Constitution Life Construction Workers Corestar DMERC B/Administar EBC ECI Health and Welfare Plan Employee Benefit Management Corp Employers Health Eye Care of Wisconsin Eye Care Plan Of America - Region 1 EyeMed Eyemed Discount Program Farmers Insurance Group First Health Network Fiserv Health Gallagher Bassett Service General American Golden Rule Great West Healthcare Gtl H.e.p. Administrators, Inc HCN Healtheos By Multiplan Healthpartners Humana Humana Gold/EyeMed Disc Insurtec John Alden Health Mason 8 Health Fund Medical Eye Services Medicare Medicare Complete Midwest Security Administrators Milwaukee Carpenters Health Fund Milwaukee Painters Local 781 Mutual of Omaha National Vision Administrators New Insurance none-no insurance coverage Operating Engineers Optum OTHER P5 Health services Inc. Physicians Plus Plumbers Local 75 Health Fund Principal Financial QuadMed Railroad Retirement Board Sample Insurance With Fee Table Sample Insurance With Plans & Fee Table Schenk SC Secure Horizons Sentry Life Sisco-Self Insured Services company State Farm Superior Vision Plan Time Insurance Company Tricare Trilogy Trustmark UMR United Health Allies Discount United Health Care United Teachers Associates Village of Sussex Vision care of Tampa Vision Insurance Plan of America Vision Service Plan Visioncare Plan Washington National Ins/Conseco Wausau WEA West Bend Mutual Insurance Company WI Sheet Metal Workers Health Fund Wisconsin Laborers Wisconsin Mason's Health Fund Wisconsin Pipe Trades Health Fund Wisconsin Ufcw Unions & employees Workman's Compensation WPPN/MULTIPLAN Wps
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

CHIEF COMPLAINT

distance vision blurry near vision blurry vision blurry distance and near red eye pain in eye loss of vision injury to eye needs new glasses wants to be fitted for contacts itching burning stinging dry eyes Diabetic eye exam

Location:

Both Right Left

Quality:

constant throbbing better worse no change

Severity:

Mild Moderate Severe

Duration:

1 day 2 days 3 days 4 days 5 days 6 days 1 week 1 month 3 months 6 months 1 year

Timing:

Always Sometimes AM PM

Context:

computer outside

Modifying:

Medication Glasses help Drops help

Associated:

dizzy headache loss of vision blurred vision eye pain

Secondary Complaints:

HEADACHES

PATIENT OCULAR HISTORY: Injuries, Infections, Surgeries, Diseases

Itching Burning, Stinging Amblyopia Eye Injuries Eye Surgery Flashes Of Light Floaters Strabismus Cataracts Glaucoma Retinal Disorders None

Eye Meds:

None Cromolyn NA 4% Visine Patanol Xalatan Travatan rewetting drops Elestat Vigamox Alphagan Refresh Theratears Genteal Pred Forte Lotemax Alrex Systane Blink

Last Eye Exam:

1 year 2 years 3 years

Doctor:

Doesn't Remember Never Lens Crafters Pearl Dr. Taylor Dr.Worthen Dr.Dale Dr.Harris Dr.Harrison-Target Dr.Buchanan

Glaucoma:

No Parents Sibling Grandparent

Cataracts:

No Parents Siblings Grandparent

Macular Degen:

No Parents Siblings Grandparent

Retinal Detach:

No Parents Siblings Grandparent

Crossed / Lazy:

No Parents Siblings Grandparent

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA

Planning to get new glasses?

Yes No

Back up specs?

Yes No

Type of CLs worn in past:

None Disposable Conventional Colored RGP PMMA

Wear Time:

8 - 10 Hours All day Occ. Overnight Extended

Cleaner:

Optifree Clear Care Boston Renu

Disposal:

2 weeks monthly daily weekly yearly

NOTES:

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