New Patient Paperwork

New Patient Paperwork
Patient Name*

First NameLast Name
Patient Date of Birth

MonthDayYear
Gender*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is it okay to call/text You?*

YesNo
Occupation:
If a student, what grade?
Please upload a photo of your valid driver’s license or government-issued ID:

Cancelof
Do you have insurance?*
Please upload a clear photo of the FRONT of your insurance card:

Cancelof
Please upload a clear photo of the BACK of your insurance card:

Cancelof
Has anyone is your household been a patient before?
How did you hear about our office?
Who can we thank for referring you to us?
Hours spent on electronic devices (computer, iPad, iPhone)
What was your last eye exam?

MonthDayYear
Date
Do you wear glasses?

YesNo
Do you wear contact lenses?

YesNo
Do you need a contact lens exam?

YesNo
Primary Care Physician:
Last physical:

MonthDayYear
Date
Do you have any allergies to medication?
If yes, list allergies.
Are you able to make financial decisions for yourself?
Select all health issues, if any:

High Blood PressureDiabetesChoesterolThyroidCancerPregnantOtherNone
Have you had any major surgeries? If yes, please list:
Please list all current medications:
Your pharmacy name/location:
HIPPA COMPLIANCE ACKNOWLEDWe respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of private practices. We protect your health information and what rights you have regarding it. If we need to disclose your health information outside of our office we will ask for your written permission. If you would like a copy of this policy please feel free to ask for one. *
Signature*

Powered by Jotform SignClear
Should be Empty: