New Patient Form

Name*

Preferred Name*

Birthdate*

Address*

Zip Code*

Mobile Phone*

Secondary Phone

Email*

SSN*

Marital Status

Language

Ethnicity

Sex*
MaleFemaleOther

Emergency Contact*

Relation*

Phone*

Reason for Visit*
Yearly Eye ExamNeed Glasses/Contact LensesMedical Eye ProblemOther

Do you wear Glasses?*
YesNo

If yes, when do you wear them?

Do you wear Contact Lenses?*
YesNo

If yes, what brand?

Are you currently having any of the following eye problems? *
HeadachesDry EyesDischargeEye InjuryLoss of visionLight SensitivityBurningRednessEye PainBlurred visionEyestrainWatering/TearingItchingFlashesGlareMotion SicknessScratchy/GrittyAllergiesFloatersHalosComputer DiscomfortSore/IrritatedEye InfectionDouble VisionStyes

Eye Surgeries/Procedures*

Date of Surgery

Eye Drops

Do you have or have you ever had any of the following medical problems?*
CataractsRetina Defect/DiseaseCancerHepatitisParkinson’sDiabetic RetinopathyConcussionCholesterolHigh Blood PressureSkin ConditionGlaucomaMigrainesChemical AddictionKidney/Liver DiseaseShinglesIritis/UveitisAIDS/HIVDiabetesLupusStrokeKeratoconusArthritisDrug SensitivityMultiple SclerosisThyroid DiseaseLazy/Turned EyeAsthmaEmphysemaPacemakerTuberculosisMacular DegenerationBleeding DisorderHeart Condition