New Patient Form (click submit at the bottom of the medical history tab when finished)
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
Annulled
Divorced
Domestic partner
Interlocutory
Legally Separated
Married
Never Married
Polygamous
Widowed
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Pak, Peter
Dr. Pak, Linda
Dr. Colorado, O.D., Stephanie
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
All Savers - UHC
Always Care - First look Vision Network
Avesis
Block Vision
Blue Cross Blue Shield
Blue Cross TX
Cigna (Medical Only)
Cigna Vision (VSP)
Coventry Health
Davis
Definity Health - UHC
Golden Rule - UHC
Humana
Humana Medicare
Medicare - Medicare
MES Vision
Metlife Vision (VSP)
Multiplan/PHCS
New Insurance
Opticare of Utah
Oxford - UHC
Pacificare - UHC
PHCS
Spectera
Superiorvision
TML (Get primary name, DOB)
Tricare
UMR - Fiserv/Benefit Planners
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
Aetna
All Savers - UHC
Always Care - First look Vision Network
Avesis
Block Vision
Blue Cross Blue Shield
Blue Cross TX
Cigna (Medical Only)
Cigna Vision (VSP)
Coventry Health
Davis
Definity Health - UHC
Golden Rule - UHC
Humana
Humana Medicare
Medicare - Medicare
MES Vision
Metlife Vision (VSP)
Multiplan/PHCS
New Insurance
Opticare of Utah
Oxford - UHC
Pacificare - UHC
PHCS
Spectera
Superiorvision
TML (Get primary name, DOB)
Tricare
UMR - Fiserv/Benefit Planners
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:
Tertiary
Insurance Information
Insurance Name:
None
Aetna
All Savers - UHC
Always Care - First look Vision Network
Avesis
Block Vision
Blue Cross Blue Shield
Blue Cross TX
Cigna (Medical Only)
Cigna Vision (VSP)
Coventry Health
Davis
Definity Health - UHC
Golden Rule - UHC
Humana
Humana Medicare
Medicare - Medicare
MES Vision
Metlife Vision (VSP)
Multiplan/PHCS
New Insurance
Opticare of Utah
Oxford - UHC
Pacificare - UHC
PHCS
Spectera
Superiorvision
TML (Get primary name, DOB)
Tricare
UMR - Fiserv/Benefit Planners
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
Reason for visit
Occupation
Hobbies:
Last Eye Exam
Interested In Contact Lenses?
yes
no
Other
Referred By:
Personal Ocular History
Eye Meds:
Last Eye Doctor:
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:
Family Eye History:
Allergies:
NOTES:
Submit Data
Please press submit when finished