New Patient Form

Demographics

TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
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
Race Ethnicity Preferred Language
Smoking Status
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:
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:
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:
Employer/School:

Medical History

Please list any medical condition that you are currently being treated for: (Diabetes, HBP, Arthritis, Asthma, Heart , Seizures, Thyroid etc)
Please list any eye condition that you have had: (Injuries, Infections, Surgeries, Diseases etc)
Medications you are currently taking:
Occupation:
Employer:
Date of Birth:
Age:
Allergies:
Injuries, Surgeries, Hospitalizations:
Primary Care Physician:
Are you currently using any eye medications:
Last Eye Exam:
Last Eye Doctor:
Hobbies:
Please list your family medical history: (Diabetes,HBP,Arthritis,Thyroid etc)
Please list your family eye history: (Glaucoma,Cataract,Macular Deg.,Lazy Eye etc)
Are you interested in Lasik? Do you use a computer?
Hours Per Day
Interested In CL New Wearer Previous Wearersoft soft toricrgpsoft mono/bi
How often do you replace your lenses?
What lens solution do you use?

Submit Data

After Completing All Forms Submit Data on Final Tab