New Patient Form

Demographics

How Did You Hear About Us? (Select One) Facebook Frame Vendor Google Instagram Insurance Newspaper Other Search Engine Walk/Drive by Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Fr. Miss

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	Single Married Separated Divorced Widowed Unknown	Employer/School Name
Primary Doctor		Misc/Guardian

Preferred Language: English Spanish French Other Patient Declined to Specify

Ethnicity:  Hispanic or Latino Not Hispanic or Latino Unknown Patient Declined to Specify   Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Patient Declined to Specify Other

Billing Information

Is The Billing Address the Same?

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

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 Aetna Blue Cross Blue Shield Blue VIsion Cigna Davis Vision Eyemed Medicaid Medicaid Medicare Spectera Eyecare Network United Health Care VSP
Insurance Plan:
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 Aetna Blue Cross Blue Shield Blue VIsion Cigna Davis Vision Eyemed Medicaid Medicaid Medicare Spectera Eyecare Network United Health Care VSP
Insurance Plan:
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:

Vision Plan

Insurance Information

Insurance Name:	None AARP Aetna Blue Cross Blue Shield Blue VIsion Cigna Davis Vision Eyemed Medicaid Medicaid Medicare Spectera Eyecare Network United Health Care VSP
Insurance Plan:
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 Vision Issues For This Visit

PATIENT MEDICAL HISTORY Please list any systemic history (include diabetes, hypertension, cancer, autoimmune disorders, etc.)

If diabetic what year were you diagnosed
Last a1c

Please list any Injuries, Surgeries, Hospitalization

Pregnant Or Nursing: No Yes Unsure Not Pregnant but nursing Not Nursing but pregnant

Primary Care Physician: Last Visit: 1 week 1 month 3 months 6 months 1 year 2 years

   Please list your current Prescription Medications (including vitamins and over-the-counter meds):
No Current Medications

Please list all drug allergies: No Known Drug Allergies

PATIENT OCULAR HISTORY
Please indicate below if you have had any of the following: Amblyopia, Dry Eyes, Eye Injuries, Eye Surgery, Flashes of Light, Floaters, Strabismus, Cataracts, Glaucoma, or Retinal Disorders

Please enter your current Eye Medications:

Last Eye Doctor: Last Eye Exam: 1 year 2 years 3 years over 3 years  

Primary Vision Correction:  None Glasses-Full Time Glasses-Readers Only Contacts - Soft RGPs PMMA

Type of CLs worn in past: None Disposable Conventional Colored RGP PMMA  Wear Time: 8 - 10 Hours All day Occ. Overnight Extended Disposal: 2 weeks monthly daily weekly yearly

DO YOU CURRENTLY HAVE ANY OF THESE PROBLEMS?

GENERAL: Fever, weight loss, weight gain, fatigue?
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
SKIN: growths, rashes, acne
NEUROLOGICAL: Headaches, migraines, seizures
PSYCHIATRIC: Depression, Anxiety, Insomnia
 ENDOCRINE: Thyroid, Diabetes
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, M.S., Lupus, HIV
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux


Smoking Status: Never smoker (<100 cigs equiv) Former smoker (no longer smokes) Current some day smoker (not daily) Light smoker (<10 cigs/day) Heavy smoker (>10 cigs/day) Smoker (current status unknown) Current every day smoker Unknown if ever smoked Other

Alcohol: No Yes Occasionally Socially Other

FAMILY MEDICAL HISTORY
Please list any systemic family history (include diabetes, hypertension, cancer, autoimmune disorders, etc.)


FAMILY OCULAR HISTORY

Please list any ocular family history (including cataracts, glaucoma, macular degeneration, retinal disorders, etc)

Submit Data