New Patient Form

Demographics

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

Address:
City:		State/ZipCode	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

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	Unknown Single Married Separated Divorced Widowed Child	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. Porter, Lisa Dr. King, Kenneth Dr. Clark, Melanie	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

Address

City	State	ZipCode
	TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None AARP ACS Aetna Allegiance Allstate Altius Ameriben American Heatlhcare Alliance Ameritas Life Ins. Corp Association & Society Insurance Corporation Assurant Health Asuris Northwest Health Auxiant Avesis Bankers Life & Casualty Company Benefit MD Best Life BlueCross of Idaho Boulder Administration Services, Inc CBA Central United Life Insurance Company ChampVA Chesterfield Resources, Inc. CIGNA Cigna Vision Davis Vision Insurance DMBA EBMS Eight District Electrical Benefit Fund Eyemed Claims Farm Bureua Farmers Insurance First Choice Health PPO Network First Choice of Midwest First Health Network GEHA Gerber Life Insurance Company Great West Healthcare Group Health Health Claims Service Health Comp HealthScope Benefits Humana IBEW/Western Utilities Health and Welfare Trust Fund Idaho Division of Vocational Rehabilitation Idaho Pipe Trades H&W Trust Idaho State Idaho State Insurance Fund Inland Empire Teamsters Trust International Benefits Administrators IPN Ironworker's Intermountain Health & Welfare Trust JAS Inc. LifeMap LifeWise Health Plan of Oregon Logistics Health, Inc Loyal American M S Administrative Services Inc MBA Benefit Administrators Inc. Medco Medi-Share Medicaid: Molina Medicare Part B: Noridian Mega Life & Health Insurance Company Meritain Health Mid-West Life Insurance Co. of TN Mutual of Omaha New Insurance New Insurance New Insurance Noridian Noridian Administrative Services Nothwest Sheet Metal Workers ODS Opticare of Utah Optum Health Vision PacificSource Health Plans PCIP Prestige Claims Office Public Employees Health Program Regence Blueshield of Idaho Rehn & Associates Samba Security Administrative Services Security Life Insurance Company of America Select Health Smith Administrators Spectera State Farm State Farm Insurance State of Idaho State of Washington Superior Vision Tall Tree Administrators The Mail Handlers Benefit Plan Todays Options Tricare West Region UMR United Commerical Travelers United Health Care United Healthcare United of Omaha Life Insurance Co. UnitedHealth Group UnitedHealth Integrated Services Utah-Idaho Teamsters Security Fun Vision Benefits of America Vision Care Direct Vision Service Plan Woodmen of the World WPS Triwest
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 AARP ACS Aetna Allegiance Allstate Altius Ameriben American Heatlhcare Alliance Ameritas Life Ins. Corp Association & Society Insurance Corporation Assurant Health Asuris Northwest Health Auxiant Avesis Bankers Life & Casualty Company Benefit MD Best Life BlueCross of Idaho Boulder Administration Services, Inc CBA Central United Life Insurance Company ChampVA Chesterfield Resources, Inc. CIGNA Cigna Vision Davis Vision Insurance DMBA EBMS Eight District Electrical Benefit Fund Eyemed Claims Farm Bureua Farmers Insurance First Choice Health PPO Network First Choice of Midwest First Health Network GEHA Gerber Life Insurance Company Great West Healthcare Group Health Health Claims Service Health Comp HealthScope Benefits Humana IBEW/Western Utilities Health and Welfare Trust Fund Idaho Division of Vocational Rehabilitation Idaho Pipe Trades H&W Trust Idaho State Idaho State Insurance Fund Inland Empire Teamsters Trust International Benefits Administrators IPN Ironworker's Intermountain Health & Welfare Trust JAS Inc. LifeMap LifeWise Health Plan of Oregon Logistics Health, Inc Loyal American M S Administrative Services Inc MBA Benefit Administrators Inc. Medco Medi-Share Medicaid: Molina Medicare Part B: Noridian Mega Life & Health Insurance Company Meritain Health Mid-West Life Insurance Co. of TN Mutual of Omaha New Insurance New Insurance New Insurance Noridian Noridian Administrative Services Nothwest Sheet Metal Workers ODS Opticare of Utah Optum Health Vision PacificSource Health Plans PCIP Prestige Claims Office Public Employees Health Program Regence Blueshield of Idaho Rehn & Associates Samba Security Administrative Services Security Life Insurance Company of America Select Health Smith Administrators Spectera State Farm State Farm Insurance State of Idaho State of Washington Superior Vision Tall Tree Administrators The Mail Handlers Benefit Plan Todays Options Tricare West Region UMR United Commerical Travelers United Health Care United Healthcare United of Omaha Life Insurance Co. UnitedHealth Group UnitedHealth Integrated Services Utah-Idaho Teamsters Security Fun Vision Benefits of America Vision Care Direct Vision Service Plan Woodmen of the World WPS Triwest
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 AARP ACS Aetna Allegiance Allstate Altius Ameriben American Heatlhcare Alliance Ameritas Life Ins. Corp Association & Society Insurance Corporation Assurant Health Asuris Northwest Health Auxiant Avesis Bankers Life & Casualty Company Benefit MD Best Life BlueCross of Idaho Boulder Administration Services, Inc CBA Central United Life Insurance Company ChampVA Chesterfield Resources, Inc. CIGNA Cigna Vision Davis Vision Insurance DMBA EBMS Eight District Electrical Benefit Fund Eyemed Claims Farm Bureua Farmers Insurance First Choice Health PPO Network First Choice of Midwest First Health Network GEHA Gerber Life Insurance Company Great West Healthcare Group Health Health Claims Service Health Comp HealthScope Benefits Humana IBEW/Western Utilities Health and Welfare Trust Fund Idaho Division of Vocational Rehabilitation Idaho Pipe Trades H&W Trust Idaho State Idaho State Insurance Fund Inland Empire Teamsters Trust International Benefits Administrators IPN Ironworker's Intermountain Health & Welfare Trust JAS Inc. LifeMap LifeWise Health Plan of Oregon Logistics Health, Inc Loyal American M S Administrative Services Inc MBA Benefit Administrators Inc. Medco Medi-Share Medicaid: Molina Medicare Part B: Noridian Mega Life & Health Insurance Company Meritain Health Mid-West Life Insurance Co. of TN Mutual of Omaha New Insurance New Insurance New Insurance Noridian Noridian Administrative Services Nothwest Sheet Metal Workers ODS Opticare of Utah Optum Health Vision PacificSource Health Plans PCIP Prestige Claims Office Public Employees Health Program Regence Blueshield of Idaho Rehn & Associates Samba Security Administrative Services Security Life Insurance Company of America Select Health Smith Administrators Spectera State Farm State Farm Insurance State of Idaho State of Washington Superior Vision Tall Tree Administrators The Mail Handlers Benefit Plan Todays Options Tricare West Region UMR United Commerical Travelers United Health Care United Healthcare United of Omaha Life Insurance Co. UnitedHealth Group UnitedHealth Integrated Services Utah-Idaho Teamsters Security Fun Vision Benefits of America Vision Care Direct Vision Service Plan Woodmen of the World WPS Triwest
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

Vision Insurance

None Avesis Block Chip Coast to Coast Davis Gateway Keystone Health Plan West March Vision Security Blue Spectera Superior Tricare UPMC

Medicare Patient

Medical Insurance

None Medicare Blue Cross/Blue Shield Gateway HealthAmerica Keystone Health Plan West March Vision United Healthcare UPMC

Interested In Contact Lenses?

No Yes

Ever Worn Contact Lenses?

No Yes

Contact Lens Brand Worn:

Acuvue lenses Bausch&Lomb lenses Ciba lenses Coopervision lenses Ocular Science lenses Rigid Gas Perms

Last Eye Doctor:

Primary Care Physician:

Current Meds:

Allergies

None Known All Cillins Environmental Latex Penicillin Seasonal Sulfa

Medical History

Pregnant or Nursing

Family Med History:

None Arthritis Cancer Diabetes I Diabetes II Hypertension Hypercholesterolmia Heart Dx None Known

Illegal Drug Use

Family Eye History:

None Amblyopia Cataracts Glaucoma Macular Degeneration Retinal Detachment Lazy Eye Blindness

Smoke

Exposure to Infectious Disease

No

NOTES/SOCIAL HISTORY

Medicaid PatientDrink

Computer Use:

Daily None Infrequent

Date

Problems with glare?

No Yes

Submit Data