New Patient Form

New Patient Paperwork
*Indicates Required Fields

Patient Information

Preferred Contact:

EmailCell PhoneHome Phone

NEW PATIENTS ONLY!!!!

If not referred, how did you hear about our office?

DoctorInsurance ListSign/BuildingMagazine/NewspaperHometown NewsWebsite

Insurance Information

Primary Medical Insurance

Subscriber Name

Secondary Medical Insurance

Subscriber Name

Vision Insurance

Subscriber Name

Lifestyle Questions

Do you…. (Check if your answer is “YES”)

work at a computer?have interest in contact lensesspend time outdoors? have prescription sun wear?prefer not to wear glasses at timeswant info on Laser Vision Correction?have more than 1 pair of current RX eyewear?

Have you tried contacts?*

YesNo

Do you currently wear contact lenses?*

YesNo

Are you satisfied with your current bifocal/progressive lenses?

YesNo

Do you sleep in your contacts?

YesNo

Are you satisfied with your current bifocal/progressive lenses?

YesNo

Have you used transition lenses?

YesNo

Patient Medical History

Allergies to medications?*

YesNo

Have you had any previous surgeries?*

YesNo

Do you use cigarettes/tobacco?*

YesNo

Have you ever been diagnosed or treated for the following health problems

NoneAllergiesBlood/LymphCancerDiabetesEars/Noes/ThroatFatigueKidneyNeurologicalRespiratoryArthritisBronchitisCholoesterolDigestiveEndocrineGenitourinaryIntegumentary (Skin)Muscle / BonePsychologicalThyroidUnusual Weight Loss / Gain

Family Medical/ Eye History (Check all that apply)

Is there a family medical history of any of the following:* (Mother’s or Father’s side)

NoneBlindnessCataractsCorneal ProblemsGlaucomaHeart DiseaseLazy EyeMacular DegenerationRetinal Problems