New Patient Information
|
| Name
*
|
|
| Prefix
|
|
| First
*
|
|
| Last
*
|
|
| Suffix
|
|
| Address
|
|
| Street Address
|
|
| Address Line 2
|
|
| City
|
|
| State / Province / Region
|
|
| Postal / Zip Code
|
|
| Country
|
|
| Email
|
|
| Confirm
| |
| Home Phone Number
*
|
|
| Cell Phone Number
|
|
| Your birthdate
*
|
|
| Employer
|
|
| Work Phone Number
|
|
| Name of Vision Coverage
|
|
| Name of Policy Holder
|
|
| Vision ID Number
|
|
| Policy Holder's Date of Birth
| We need this information to determine your vision coverage
|
| Last four digits of Social Security Number
| We need this information to determine your vision coverage.
|
| Name of Health Insurance
| Please bring your health insurance card and ID to your appointment
|
| Health insurance ID number
|
|
| If under 18, parent's full name
|
|
| List any allergies
|
|
| List any eyedrops you are taking
|
|
| List any medications your are taking
| If you are taking more than what can fit in space, please bring list to your appointment.
|
| Please check any of the conditions that you have or have had.
| Crossed Eyes Head Injury Cataracts Diabetes High Blood Pressure Glaucoma Macular Degeneration
|
| Do you have a family history of (blood relations only)
| Glaucoma Macular Degeneration Diabetes Retinal Detachment
|
| Have you had eye surgery (includes LASIK)?
| Yes No
|
| If yes, what type of surgery and when?
|
|
| Have you had an eye injury?
| Yes No
|
| If yes, what kind and when?
|
|
| Do you wear eyeglasses?
| Yes No
|
| Do you wear contacts?
| Yes No I used to, until they became too uncomfortable
|
| If you wear contacts now, what type?
| Soft Oxygen Permeable I'm not sure
|
| If you wear contacts, how long do you use one pair for?
| 1 Day 1 week 2 Weeks 1 month Until they feel uncomfortable Other
|
| If you don't wear contacts now, would you be interested in finding out more about them?
| Yes No Maybe
|
| How did you find out about us?
| Insurance List Internet Search Yellow Pages New Resident Letter Walk-In, Saw sign Referral
|
| If a referral, please let us know who so we can thank him/her.
|
|
We want to provide you with the best care possible. To do that we need to know a little about your vision needs. Please take a few minutes to answer the following questions.
|
| How many hours a day do you use a computer?
|
|
| Check any problems you might have with your vision while using the computer
| Eyes Burn or Sting Eyes Feel Tired or Strained Blurry Vision Headaches
|
| Do you enjoy any of the following hobbies or sports?
| Golf Tennis Swimming Raquetball Biking Boating Fishing Dive/Snorkel
|
| Do you use sports glasses?
| Yes No
|
| Check any problems you may have with your current glasses
| Scratches Slip Down Inconvenient Uncomfortable Reflections Marks on Nose Lenses too thick/heavy Bifocals a problem
|
| UV light can cause cataracts, macular degeneration and other diseases. Do your eyeglasses protect your eyes from UV light?
| Yes No I don't know
|
All major health insurances and Medicare now require us to obtain in-depth patient medical history information. We apologize for the time required to fill out this form and thank you for your cooperation.
|
| Any loss of vision
| Yes No
|
| Double Vision
| Yes No
|
| Dryness
| Yes No
|
| Redness
| Yes No
|
| Sandy or gritty feeling
| Yes No
|
| Burning
| Yes No
|
| Itching
| Yes No
|
| Tearing or Watery
| Yes No
|
| Glare/Light Sensitivity
| Yes No
|
| Flashes or Floaters
| Yes No
|
| Sinus Congestion
| Yes No
|
| Chronic Cough
| Yes No
|
| Hyperthyroidism
| Yes No
|
| Hypothyroidism
| Yes No
|
| Rheumatoid Arthritis
| Yes No
|
| Skin Cancer
| Yes No
|
| Acne Rosacea
| Yes No
|
| Asthma
| Yes No
|
| Chronic Bronchitis
| Yes No
|
| Headaches
| Yes No
|
| Migraines
| Yes No
|
| Anemia
| Yes No
|
| Vascular Disease
| Yes No
|
| Chest Pain
| Yes No
|
| Do You Drive?
| Yes No
|
| If yes, do you have visual difficulty when driving?
| Yes No
|
| Do you use tobacco products
| Yes No
|
Thank you!
Now please click on the "Send" button below.
|
|
Image Verification
|
|
|
|
|
|