New Patient Form

Legal Name

Address

Home phone number

Cell Phone number

Email address

Date of Birth

Insurance provider

Policy and group number

Main subscriber to insurance (self, spouse, etc)

If not self, provide name and date of birth of subscriber

Occupation

What is your reason for coming in today?

Do you wear glasses?

Do you wear contact lenses?

List any history of lazy eye, patching, eye injury, eye surgeries etc

Are you taking any medications for your eyes (please include over the counter)?

List any history of lazy eye, patching, eye injury, eye surgeries etc

Are you taking any medications for your eyes (please include over the counter)?

Please list any allergies to medication

Any family history of eye diseases (glaucoma, cataracts, macular degeneration, etc)

Do you use tobacco?

Are you pregnant?

Who is your Primary care physician?

Review of systems: please respond to any that apply

General (fever, wight loss or gain, fatigue)

Review of systems: please respond to any that apply

General (fever, wight loss or gain, fatigue)

Ear, Nose, Throat (allergies, sinus, cough, dry mouth)

Cardiovascular (hypertension, heart disease)

Respiratory (asthma, bronchitis, COPD)

Genital, kidney, bladder (kidney stones, frequent urination)

Muscle, bone, joints (Arthritis, head or neck injury)

Skin (growths, rashes)

Neurological (Headache, migraines, seizures)

Psychiatric (Depression, anxiety, insomnia)

Blood/lymph (Anemia, Cholesterol)

Gastrointestinal (reflux, diarrhea, constipation, IBS)

Autoimmune (RA, AIDS, Lupus)

Endocrine (thyroid, diabetes)

New Patient Form

Contact Information

Hours of Operation

New Patient Form

Contact Information

Hours of Operation

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