New Patient Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Miss

Address:
City:		State/ZipCode	TX

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	Employer/School Name
Primary Doctor	No Doctor Assigned Dr. LEAZURE, MARY Dr. CASTRO, JANET Dr. BHAGA, SHEETAL Dr. EISENBERG, LESTER Dr. Temp, Temp	Misc/Guardian

Billing Information

Is The Billing Address the Same?

Title	First	Last	MI	Suffix
Mr. Mrs. Miss

Address

City	State	ZipCode
	TX

Home Phone:
Work Phone:

Primary

Insurance Information

Insurance Name:	None ACS BENEFITS SERVICES, INC AETNA Aetna Vision Discount AMERICAN MEDICAL SECURITY AVESIS BEECH STREET BLOCK VISION BLUE CROSS BLUE SHIELD CIGNA DAVIS VISION Discount EYEMED FIRST HEALTH-OUT OF NETWORK GPA MEDICAL GREAT WEST GROUP RESOURCES HARVARD PILGRIM HEALTH FIRST Health Smart We are out of network HUMANA INNOVANTE BENEFIT ADMINISTRATORS KAW NATION MEDICAL MUTUTAL-Out of Network MEDICARE PART B MERITAIN HEALTH MES VISION MultiPlan NVA OPTICARE-TOTAL VISION OXFORD HEALTH PLAN PALMETTO GOV'T BENEFITS Pending Insurance Verification PHCS PP PRINCIPLE EDGE PRINCIPLE FINANCIAL GROUP SPECTERA /OPTUM HEALTH/UHC VISION SUPERIOR VISION Services, Inc TEXAS TRUE CHOICE-Out of Network TML UMR UNICARE/HEALTHLINK UNITED HEALTHCARE VISION BENEFITS OF AMERICA VISION CARE PLAN/MY COMP BENEFITS 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 ACS BENEFITS SERVICES, INC AETNA Aetna Vision Discount AMERICAN MEDICAL SECURITY AVESIS BEECH STREET BLOCK VISION BLUE CROSS BLUE SHIELD CIGNA DAVIS VISION Discount EYEMED FIRST HEALTH-OUT OF NETWORK GPA MEDICAL GREAT WEST GROUP RESOURCES HARVARD PILGRIM HEALTH FIRST Health Smart We are out of network HUMANA INNOVANTE BENEFIT ADMINISTRATORS KAW NATION MEDICAL MUTUTAL-Out of Network MEDICARE PART B MERITAIN HEALTH MES VISION MultiPlan NVA OPTICARE-TOTAL VISION OXFORD HEALTH PLAN PALMETTO GOV'T BENEFITS Pending Insurance Verification PHCS PP PRINCIPLE EDGE PRINCIPLE FINANCIAL GROUP SPECTERA /OPTUM HEALTH/UHC VISION SUPERIOR VISION Services, Inc TEXAS TRUE CHOICE-Out of Network TML UMR UNICARE/HEALTHLINK UNITED HEALTHCARE VISION BENEFITS OF AMERICA VISION CARE PLAN/MY COMP BENEFITS 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 ACS BENEFITS SERVICES, INC AETNA Aetna Vision Discount AMERICAN MEDICAL SECURITY AVESIS BEECH STREET BLOCK VISION BLUE CROSS BLUE SHIELD CIGNA DAVIS VISION Discount EYEMED FIRST HEALTH-OUT OF NETWORK GPA MEDICAL GREAT WEST GROUP RESOURCES HARVARD PILGRIM HEALTH FIRST Health Smart We are out of network HUMANA INNOVANTE BENEFIT ADMINISTRATORS KAW NATION MEDICAL MUTUTAL-Out of Network MEDICARE PART B MERITAIN HEALTH MES VISION MultiPlan NVA OPTICARE-TOTAL VISION OXFORD HEALTH PLAN PALMETTO GOV'T BENEFITS Pending Insurance Verification PHCS PP PRINCIPLE EDGE PRINCIPLE FINANCIAL GROUP SPECTERA /OPTUM HEALTH/UHC VISION SUPERIOR VISION Services, Inc TEXAS TRUE CHOICE-Out of Network TML UMR UNICARE/HEALTHLINK UNITED HEALTHCARE VISION BENEFITS OF AMERICA VISION CARE PLAN/MY COMP BENEFITS 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

Referred By:

Insurance Friend/Family Website/Internet Yellow Pages Walk-by/Drive-by Former Patient

Referring Doctor:

Family Patients:

None Wife Husband Children Parent

Hobbies:

Interested In Contact Lenses?

no yes wears contacts

Ever Worn Contact Lenses?

No yes

Type of CLs worn in past:

none Disposables Extended Wear Gas Permeables Gas Perm Bifocals Gas Perm Bitorics Gas Perm FS Toric Monovision - Soft Monovision - Disposables Monovision - Gas Perm No CL Hx Soft Daily Wear Soft Torics

Back up specs for cls?

Yes No

Primary Vision Correction:

Bifocals Contacts Contacts - Mono None Progressives Single Vision Trifocals

Sunspecs?

Yes No

Computer glasses?

Yes No

Problems with glare?

Yes No

Interested in Laser Vision Correction?

Not Interested Yes

Eye Hx: Sting, Burn, Itch, Surg.,Injury,Cats, Ambly.,Floaters, GL, Strab., Retinal

None Allergies Abrasion Blind Eye Blepheroplasty Cataract - OU Cataract - OD Cataract - OS Conjunctivitis Dry Eye Glaucoma IOL - OU IOL - OD IOL - OS Metal in Eye Ptosis Retinal Detach Weak Eye Lazy Eye

Eye Meds:

NONE Artificial Tears Acular Antibiotic Betoptic-S .25% Betoptic .5% Betagan Erythromycin FML FML Forte Gentamicin Neosporin Ocupress Pilo Gel Propine Polytrim Pred Mild Pred Forte Pataday Patanol Timoptic .25% Timoptic .5% Tobradex Voltaren Xalatan Vigamox Glaucoma Meds

Last Eye Doctor:

Does not remember Dr. Leazure Dr. Castro Pearl Dr. Lens Crafter's Dr. Eyemasters Target Dr. Wal-Mart Dr. Dr. Shannon

Primary Care Physician:

Systemic Meds:

Med Hx: HAs,Arthritis,Asthma,Diabetes,HBP,Heart,Infl. Bowel Dz,Seizures,Thyroid,Smoke,Pregnant,Nursing,HIV+

Family Med History:

None Known Artheritis Cancer Diabetes Hypertension Hypercholesterolmia Heart Dx

Family Eye History:

NONE Amblyopia Cataracts Glaucoma Macular Degeneration Retinal Detachment Weak Eye Lazy Eye

Medication and Seasonal Allergies:

NONE Erythromycin Iodine Pollen PCN Sulfa Codeine Tetanus NKDA Seasonal Allergies

NOTES/SOCIAL HISTORY

OCCUPATION

TEACHER NURSE LAWYER BANK TELLER ENGINEER DOCTOR

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