New Patient Form

Demographics

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

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	No Doctor Assigned Dr. Kitchen, Lester Dr. Carroll, Johnathan	Misc/Guardian

Billing Information

Is The Billing Address the Same?

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

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 Medical

Insurance Information

Insurance Name:	None AETNA LIFE INS BANKERS LIFE BEECH STREET BENEFIT PLANNERS, INC BLOCK VISION BLUE CROSS BLUE SHIELD OF TEXAS CIGNA PPO CO-MANAGEMENT FOR SURGERY COLLECTIONS EMPLOYERS VISION PLANN OASIS EQUITABLE LIFE CASUALTY EYEMED/ ECPA EYETOPIA FIRST HEALTH GOLDEN RULE GOVERNMENT EMPLOYEE HOSP ASSO GREAT WEST-CIGNA GUARDIAN HEALTH SELECT-UNITED HEALTH CARE HMO EPO EPN- DO NOT ACCEPT HUMANA GROUP HEALTH PLAN HUMANA MEDICARE ADVANTAGE ERS MEDICARE PART B MEDICARE SUPPLEMENT, OTHER METLIFE VISION OPTICARE VISION PLANS OTHER INSURANCE PHCS Principal Life SPECTERA/UNITED/OPTUM SUPERIOR VISION PLAN TEXAS TRUE CHOICE TRICARE UNICARE UNITED HEALTH CARE VISION CARE PLAN/COMPBENEFITS VISION SERVICE PLAN WORKMANS COMP
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 Coverage

Insurance Information

Insurance Name:	None AETNA LIFE INS BANKERS LIFE BEECH STREET BENEFIT PLANNERS, INC BLOCK VISION BLUE CROSS BLUE SHIELD OF TEXAS CIGNA PPO CO-MANAGEMENT FOR SURGERY COLLECTIONS EMPLOYERS VISION PLANN OASIS EQUITABLE LIFE CASUALTY EYEMED/ ECPA EYETOPIA FIRST HEALTH GOLDEN RULE GOVERNMENT EMPLOYEE HOSP ASSO GREAT WEST-CIGNA GUARDIAN HEALTH SELECT-UNITED HEALTH CARE HMO EPO EPN- DO NOT ACCEPT HUMANA GROUP HEALTH PLAN HUMANA MEDICARE ADVANTAGE ERS MEDICARE PART B MEDICARE SUPPLEMENT, OTHER METLIFE VISION OPTICARE VISION PLANS OTHER INSURANCE PHCS Principal Life SPECTERA/UNITED/OPTUM SUPERIOR VISION PLAN TEXAS TRUE CHOICE TRICARE UNICARE UNITED HEALTH CARE VISION CARE PLAN/COMPBENEFITS VISION SERVICE PLAN WORKMANS COMP
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 AETNA LIFE INS BANKERS LIFE BEECH STREET BENEFIT PLANNERS, INC BLOCK VISION BLUE CROSS BLUE SHIELD OF TEXAS CIGNA PPO CO-MANAGEMENT FOR SURGERY COLLECTIONS EMPLOYERS VISION PLANN OASIS EQUITABLE LIFE CASUALTY EYEMED/ ECPA EYETOPIA FIRST HEALTH GOLDEN RULE GOVERNMENT EMPLOYEE HOSP ASSO GREAT WEST-CIGNA GUARDIAN HEALTH SELECT-UNITED HEALTH CARE HMO EPO EPN- DO NOT ACCEPT HUMANA GROUP HEALTH PLAN HUMANA MEDICARE ADVANTAGE ERS MEDICARE PART B MEDICARE SUPPLEMENT, OTHER METLIFE VISION OPTICARE VISION PLANS OTHER INSURANCE PHCS Principal Life SPECTERA/UNITED/OPTUM SUPERIOR VISION PLAN TEXAS TRUE CHOICE TRICARE UNICARE UNITED HEALTH CARE VISION CARE PLAN/COMPBENEFITS VISION SERVICE PLAN WORKMANS COMP
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 AETNA LIFE INS BANKERS LIFE BEECH STREET BENEFIT PLANNERS, INC BLOCK VISION BLUE CROSS BLUE SHIELD OF TEXAS CIGNA PPO CO-MANAGEMENT FOR SURGERY COLLECTIONS EMPLOYERS VISION PLANN OASIS EQUITABLE LIFE CASUALTY EYEMED/ ECPA EYETOPIA FIRST HEALTH GOLDEN RULE GOVERNMENT EMPLOYEE HOSP ASSO GREAT WEST-CIGNA GUARDIAN HEALTH SELECT-UNITED HEALTH CARE HMO EPO EPN- DO NOT ACCEPT HUMANA GROUP HEALTH PLAN HUMANA MEDICARE ADVANTAGE ERS MEDICARE PART B MEDICARE SUPPLEMENT, OTHER METLIFE VISION OPTICARE VISION PLANS OTHER INSURANCE PHCS Principal Life SPECTERA/UNITED/OPTUM SUPERIOR VISION PLAN TEXAS TRUE CHOICE TRICARE UNICARE UNITED HEALTH CARE VISION CARE PLAN/COMPBENEFITS VISION SERVICE PLAN WORKMANS COMP
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

Referred By:

Referring Doctor:

Family Patients:

Interested In Contact Lenses?

yes no

Ever Worn Contact Lenses?

Yes never worn

Type of CLs worn:

Disposable SV Disposable MF/Monovision Tinted Gas Perm Gas Perm MF/Mono SynergEyes Ortho-K/CRT Conventional

Back up specs for cls?

Yes No

Primary Vision Correction:

None Glasses-Full Time Glasses-Readers Only Glass-Dist.Only Contacts-Full Time Alternates Glasses and Contacts

Sunspecs?

Yes No

Computer glasses?

Yes No

Problems with glare?

Yes No

Interested in Laser Vision Correction?

Yes No

Occupation:

Hobbies:

None computer games Video Games Art Baseball Boating Basketball Cooking Crafts Dancing Diving Football Fishing Golf Gardening Horseback Riding Hunting Models Needlepoint Painting Photography Piano Reading Running Roller Blading Softball Sewing Skiing Soccer Swimming Tennis Woodworking

Eye Hx: Dry Eye, Allergies, Surg., Injury, Cat, Ambly., Floaters, GL, Strab., Retinal Dz

Last Eye Doctor:

Kitchen Wolf Carroll Doesn't Remember Never

Primary Care Physician:

None Doesn't Remember

Eye Meds:

None Acular .5% Ophthalmic GTTS Acular LS 0.4% ophthalmic solution Alocril "Nedocromil NA" 2% Ophthalmic GTTS Alomide .1% Ophthalmic GTTS Alphagan-P 0.15% ophthalmic gtts Alrex (loteprednol etabonate 0.2%) ophthalmic suspension Augmentin Tabs 250mg Augmentin Tabs 500mg AzaSite (azithromycin soln. 1%) Azithromycin 250mg Bacitracin Ophthalmic UNG Bepreve ophthalmic soln. Besivance ophthalmic suspension Blephamide Ophthalmic GTTS Blephamide ophthalmic ung Bromday (bromfenac 0.09%) ophthalmic solution Ceclor Tabs 250mg Ciloxan .3% Ophthalmic GTTS Cipro Tabs 250mg Claritin 10mg Tabs Cromolyn Sodium 4% Ophthalmic GTTS Cyclosporine Ophthalmic GTTS .05% Doxycycline Tabs 100mg Durezol (difluprednate 0.05%) ophthalmic emulsion Elestat ophthalmic gtts Flarex .1% Ophthalmic Suspension FML .1% Ophthalmic Suspension FML 0.1% ophthalmic ung FreshKote ophthalmic solution Homatropine 5% Ophthalmic GTTS Keflex Tabs 250mg Keflex Tabs 500mg Lastacaft (alcaftadine 0.25%) ophthalmic solution Lotemax (loteprednol etabonate 0.5%) ophthalmic ointment Lotemax (loteprednol etabonate 0.5%) ophthalmic suspension Lumigan (bimatoprost 0.01%) ophthalmic soln. Lumigan (bimatoprost 0.03%) ophthalmic soln. Maxidex Ophthalmic Solution Maxitrol .1% Ophthalmic Ointment Maxitrol .1% Ophthalmic Suspension Moxeza (moxifloxacin ophth. soln.) 0.5% Muro-128 Hypertonic GTTS Muro-128 Hypertonic Ointment Natacyn (natamycin 5%) ophthalmic suspension Nevanac ophthalmic solution Ocuflox .3% Ophthalmic GTTS Opticrom Ophthalmic GTTS Optivar (azelastine HCL) 0.05% Pataday 0.2% ophthalmic gtts Patanol .1% Ophthalmic GTTS Polysporin Ophthalmic Ointment Polytrim Ophthalmic GTTS Pred Forte 1% Ophthalmic Suspension Quixin Ophthalmic GTTS Restasis (cyclosporine ophth. emulsion) 0.05%. Disp: 2 trays Timoptic-XE 0.25% ophthalmic solution Timoptic-XE 0.5% ophthalmic solution Timoptic 0.25% ophthalmic solution Timoptic 0.5% ophthalmic solution Tobradex Ophthalmic Ointment Tobradex ophthalmic suspension Tobradex ST ophthalmic suspension Tobramycin Ophthalmic GTTS Travatan Z ophthalmic gtts triamcinolone 0.1% cream Trusopt ophthalmic solution Vicodin 10mg Tabs Vigamox Ophthalmic GTTS Vira-A (vidarabine 3%) ophthalmic ointment Viroptic (trifluridine 1%) ophthalmic solution Voltaren Ophthalmic GTTS Xalatan .005% Ophthalmic GTTS Zaditor .025% Ophthalmic GTTS Zirgan (ganciclovir 0.15%) ophthalmic gel Zylet ophthalmic susp. Zymar 0.3% ophthalmic gtts

Allergies:

None Seasonal Molds Environmental Penicillin Sulfa Drugs Proparacaine Tetracycline Codeine Iodine Perfumes NKDA

Systemic Meds:

Med Hx: HBP, Diabetes, Stroke, HAs, Arthritis, Asthma, Heart, Cancer, Seizures, Thyroid, Smoke, Pregnant, Nursing, HIV+

Family Med History:

None Diabetes HBP Stroke Cancer Adopted

Family Eye History:

None Doesn't Know Adopted Glaucoma Macular Degeneration Retinal Detachment Cataracts

NOTES:

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