Forms for New Patients

Today's Date:

Last Name:

First Name:

MI:

Sex:

M

F

Address:

City/State/Zip:

Email:

Date of Birth:

Age:

Cell Phone #

Secondary Phone #

Occupation/Field of Study & School:

Employer:

Hobbies, Artistic Interests, Sports:

Who referred you to our office?

Healthcare Provider

Optical Company

Family Member

Friend

OtherOther

Names of FAMILY MEMBERS who are patients at this office:

Please indicate method of payment:

Cash

Charge

Insurance

***CHECKS ARE NOT ACCEPTED***

(Attention: This form is not considered secure, per HIPAA. Please select “Will discuss with doctor” if you are not comfortable entering this information through the website.)

Reason for visit:

Glasses:

Contact Lenses:

Date of Last Eye Exam

Doctor's Name & City

Age of present glasses

months/years

Brand of contact lenses

Age of present contact lenses

days/weeks/months

Have you had your eyes dilated before?

Yes

No

When?

PATIENT MEDICAL HISTORY

List any medical conditions you are being treated for:

List any drugs or medications you are now taking:

List any allergies you have including allergies to medication:

Women: Are you pregnant or nursing?

Yes

No

DO YOU OR ANY FAMILY MEMBER HAVE ANY OF THE FOLLOWING? (CHECK AND INDICATE WHO HAS THE CONDITION)

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Gates Vision Care: Health & Vision History (Confidential)

PATIENT MEDICAL HISTORY