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:

Medical History

Referred By:
Referring Doctor:
Family Patients:
Hobbies:
Interested In Contact Lenses?
Ever Worn Contact Lenses?
Type of Contact Lenses worn in past:
Do you currently have a pair of glasses?
Primary Vision Correction:
Do you currently have a pair of prescription sunglasses
Do you routinely spend more than 4 hours per day on a computer?
Have you noticed problems with glare from oncoming headlights?
Are you interested in permanent Vision Correction? (LASIK, PRK, RLE)
Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal
Eye Meds:
Last Eye Doctor:
Primary Care Physician:
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
Systemic Meds:

Review of Systems

General:
Ears, Nose, Throat:
Cardiovascular:
Respiratory:
Genital, Kidney, Bladder:
Muscles, Bones, Joints:
Skin:
Neurological:
Psychiatric:
Endocrine:
Blood/Lymph:
Allergic/Immunologic
Additional Medical History Notes

Primary Insurance

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:

Submit Data

After Completing All Forms Submit Data on Final Tab