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. Nguyen, Tamanh	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 Aetna ALLIED Always Care Vision Avesis Block Vision Blue Cross Blue Shield of Texas Cigna Davis Vision First Health Network Humana National Vision Administrators New Insurance Spectera Superior Vision TML UMR United Healthcare United Healthcare Integrated Services Vision Service 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 Aetna ALLIED Always Care Vision Avesis Block Vision Blue Cross Blue Shield of Texas Cigna Davis Vision First Health Network Humana National Vision Administrators New Insurance Spectera Superior Vision TML UMR United Healthcare United Healthcare Integrated Services Vision Service 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:

Tertiary

Insurance Information

Insurance Name:	None Aetna ALLIED Always Care Vision Avesis Block Vision Blue Cross Blue Shield of Texas Cigna Davis Vision First Health Network Humana National Vision Administrators New Insurance Spectera Superior Vision TML UMR United Healthcare United Healthcare Integrated Services Vision Service 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

Ocular History:

Reason for today's visit:

Other:

When was your last eye exam?

Optometrist:

Do you wear glasses?

Y

N

Do you wear Contacts?

Y

N

If so, hard or soft?

Brand

Do you currently use eye drops(Prescription or OTC)? If so, which ones do you use?

Check all that apply:

Blurred Computer Vision	Discharge	Glare	Pain	Double Vision
Blurred Distance Vision	Dry/Watery	Lazy eye	Glaucoma	Redness
Blurred Near vision	Retinal Disorder	Loss of Vision	Flashes	Floaters
Eye Injuries/Surgeries	Cataract	Chronic Infections	Burning/Itching	Macular Degeneration

Medical History:

Last medical exam: Current Medical Doctor: Are you Pregnant or nursing?Y N

Current Medications

Allergies?

List all major injuries/surgeries:

Other Notes:

Anemia	Fatigue	Liver Disease	Cancer	Sinus Congestion	Diabetes type 1/2
Asthma	Migraine/Headache	Hypo/Hyper thyroid	Seasonal Allergies	Gastrointestinal Disorder	Kidney Disease
Arthritis	Heart Disease	Multiple Sclerosis	Tuberculosis	Urinary Tract Infection	High Cholesterol
Cerebral Palsy	Seizures	Skin Disease	Vascular Disease	Heart Attack/Stroke	Depression

High Blood Pressure

Other:

Family History

Blindness

Cancer

Glaucoma

Diabetes

Macula Degeneration

Retinal Disorder

Social History

Do you smoke?Y N

Packs per Day:

Do you drink alcohol?Y N

Drinks per Day:

Drinks per Week:

Do you use illegal drugs?Y N

Have you ever been exposed to or infected with Hepatitis/HIV/AIDS/Other?

Y

N

If so please list:

Hobbies:

Computer Use:

VISUAL FIELDS: Additional Cost of $23

This instrument checks for areas of loss of vision in both central and peripheral areas. Possible defects that may be detected early may include glaucoma, retinal problems, neurological diseases, and brain tumors. It can enable us to better diagnose the cause of headaches.

YES, I would like to be tested today

NO, I am declining at this time

DILATED FUNDUS EXAM:

Dilating the pupils with eye drops allows us to have a more thorough view in order to assess the health of the eyes. Problems such as glaucoma, cataracts, retinal detachment, macular degeneration, diabetes, and high blood pressure are better detected through dilation. The effects of the drops are light sensitivity and blurring typically during near tasks for about 3 to 4 hours.

YES, I would like to be dilated today

NO, I am declining at this time

Marking NO to either/all the additional tests will release Vision First of liability in the failure to diagnose any diseases for which these tests are useful. Please note that your vision can change in less than a year. If a follow-up is necessary to re-check your glasses/contact lens prescription, you have a 60 day grace period from the time of the original exam date for a ONE time re-check. After this period, there will be an additional fee of $30 per visit. After 6 months, a full eye exam and or contact lens fitting will be charged.

If you have read and understand the above policy regarding the follow-up appointment, please initial:

COVID 19 Screening Questions
Covid 19 Screening: Masks are REQUIRED at all times to be worn by everyone in office. We appreciate your cooperation and understanding during this time. If answering "Yes" to any of the following questions, we ask that you please cancel your appointment and reschedule at least 2 weeks after symptoms began.

Are you experiencing any new Covid Symptoms such as cough, shortness of breath, etc?	Y	N
Have you tested positive for Covid 19 in the past 2 weeks?	Y	N

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