New Patient Form
Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Once you fill in the information, click on the "Done" button to e-mail it to our office or bring a copy with you to your next appointment.


Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Once you fill in the information, click on the "Done" button to e-mail it to our office or bring a copy with you to your next appointment.
Patient Form
Closest Location:
Last Name First Name
MI
Preferred Name
Gender
M F
Address City
State / Province Zip / Postal Code
SSN (Only numeric data)
Date of Birth (MM/DD/YYYY)
Home Phone Day Phone
E-mail Guardian
Emergency Contact Phone
How were you referred to our office? Referred By?
Main reason for visit to our Office?
Last Exam Date (MM/DD/YYYY) Last Health Exam Date (MM/DD/YYYY)
Current Occupation Years
Employer
If the patient is a child:
Parent's Name Parent's Address
School Name Teacher's Name
Grade
Eye History
Headaches Yes No Blurred Vision Distance Yes No
Glare/Light Sensitivity Yes No Blurred Vision Near Yes No
Tired Eyes Yes No Distorted Vision (Halos) Yes No
Lazy Eye Yes No Double Vision Yes No
Burning Yes No Floaters or Spots Yes No
Dryness Yes No Fluctuating Vision Yes No
Excess Tearing/Watering Yes No Loss of Vision Yes No
Eye Pain or Soreness Yes No Loss of Side Vision Yes No
Foreign Body Sensation Yes No Drooping Eyelid Yes No
Infection of Eye or Lid Yes No Redness Yes No
Itching Yes No Sandy or Gritty Feeling Yes No
Mucous Discharge Yes No Crossed Eyes Yes No
Glaucoma Yes No Cataract Yes No
Macular Degeneration Yes No Retinal Detachment Yes No
Color Blindness Yes No
Family History
Lazy Eye Yes No Arthritis Yes No
Blindness Yes No Cancer Yes No
Cataract(s) Yes No Diabetes Yes No
Color Blindness Yes No Heart Disease Yes No
Glaucoma Yes No High Blood Pressure Yes No
Macular Degeneration Yes No Kidney Disease Yes No
Retinal Detachment Yes No Lupus Yes No
Eye Turn Yes No Stroke Yes No
Thyroid Disease Yes No Other Yes No
Primary Care Physician
Last Name First Name MI
Clinic  
Address  
City State Zip
Phone
Referring Physician
Last Name First Name MI
Clinic  
Address
City State Zip
Phone
Insurance
Insurance Company Insured's Name
Insured's ID Group #
Insured's DOB (MM/DD/YYYY)
Insured's Address
City State
Zip
Phone
Gender
M F
Insured's Employer
Insured's Relationship to Patient
Patient Status
Employed
Health History
Fever Yes No Kidney Yes No
Weight Loss Yes No Muscles, Bones, Joints Yes No
Other Consti. Symptoms Yes No Skin Yes No
Ears, Nose, Throat Yes No Neurological (MS) Yes No
High Blood Pressure Yes No Anxiety, Depression, Insomnia Yes No
Respiratory (Asthma) Yes No Diabetes, Thyroid Yes No
Gastrointestinal Yes No Blood/Lymph (cholesterol) Yes No
Allergic/Immunologic Yes No
Are you Pregnant? Yes No Are you Nursing? Yes No
Past Illnesses/Injuries
Past Surgeries
Current Medications
Current Eye Drops
Medications that cause reactions/sensitivities
Specific Allergies
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