New Patient Form PRINTABLE PDF Today’s Date MM slash DD slash YYYY PATIENT INFORMATIONName First Last Date of Birth MM slash DD slash YYYY AgeSex Male Female Patient’s SSNAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneEmail Address Employer (or School) Occupation (or Grade) Spouse or Parent’s Name Spouse or Parent’s Work Patient’s Race check One Hispanic/Latino Not Hispanic/Latino Preferred Language What is the major purpose of this visit?Are you experiencing any problems with your current glasses or contact lenses?Who may we thank for referring you to our office? Name of friend or relative If not referred, how did you choose our office? Another Dr Insurance List Saw Sign / Building Newspaper / Radio / TV Website: Which one? Other INSURANCE INFORMATIONPlease note that most insurance plans do NOT cover the Contact Lens EvaluationVision Insurance Subscriber Name First Last Subscriber SSNSubscriber Birth Date MM slash DD slash YYYY Primary Medical Insurance Subscriber Name First Last Subscriber SSNSubscriber Birth Date MM slash DD slash YYYY Please only complete the following if you are covered by a Secondary Insurance PlanInsurance Provider Subscriber Name First Last Subscriber SSNSubscriber Birth Date MM slash DD slash YYYY Do you have a flex spending account? Yes No LIFESTYLE QUESTIONSDo you Work at a computer? Plan on purchasing new glasses today? Think you might benefit from thinner, lighter lenses? Have prescription sunglasses? Prefer not to wear your glasses at times? Want information on Laser Vision Correction surgery? Have more than 1 pair of current Rx eyewear? Have children? Have family members in need of eyecare? Spend time outdoors? How much? Have you ever experienced, been diagnosed, or treated for any of the following? Blurry Vision Cataracts Crossed Eye/Eye Turn Eye Infections Flash of Light Glaucoma Headaches Itchiness Macular Degeneration Retinal Detachment Trouble Seeing at Night Burning Corneal Abrasion Double Vision Eye Injury Floaters/Spots Iritis/Uveitis Lazy Eye Occasional Dryness Sunlight Sensitivity Other Other PATIENT MEDICAL HISTORYName of Family Physician Address PhoneDate of Last Visit MM slash DD slash YYYY Additional Physicians you see routinely that you would like us to send your vision visits to:Doctor Address PhonePreferred Pharmacy Address PhoneCURRENT MEDICATIONS (List all including eye drops and vitamins)Allergies to MedicationsHave you had any surgeries?Are you currently Pregnant Nursing Do you: Drink Alcohol Smoke/Use Tobacco Have you ever been diagnosed or treated for the following health problems? Cancer Ears/Nose/Throat Neurological Psychiatric Cardiovascular Respiratory Gastrointestinal Gastrourital Muscular/Skeletal Integumentary (Skin) Endocrine Blood/Lymph Allergy/Immunology Please Explain: PATIENT EYE HISTORYDate of Last Eye Exam MM slash DD slash YYYY By Whom? Have you ever tried wearing contact lenses? Yes No Do you currently wear contact lenses? Yes No What kind? Solution Used If you wear bifocals, do the lines or head tilting bother you? Yes No FAMILY MEDICAL AND EYE HEALTH HISTORYCheck all that apply and list only IMMEDIATE family members. High Blood Pressure Diabetes Type 1/2 Cancer Hyper-/Hypo-thyroidism Macular Degeneration Retinal Detachment Cataracts Glaucoma HIPAA AND FINANCIAL ACKNOWLEDGMENTPlease be advised if you are using insurance coverage for today’s visit, this is a contract between you and your insurance company; not Midwest Eye Associates. I understand that I am financially responsible for all charges whether or not paid by insurance. I understand the Notice of Privacy Practices and I have been provided an opportunity to review it. If you wish to read the Notice of Privacy Practices, it is listed on our website. Patient Signature