New Patient Medical History

New Patient Registration

Please fill in the form below
Patient Name:*

First NameMiddle NameLast Name
Patient Date of Birth:*

MonthDayYear
Sex:*
Last 4 Digits of Patient's Social Security Number:*
If unknown, please enter "0000"
Patient's Occupation / Job:*
If none, please enter "None" or "N/A"
Name of Parent / Legal Guardian (if patient is under 18 years of age):
Primary Phone Number:*
Format: (000) 000-0000.
Primary Phone is a:*

Cell PhoneLandline
Email Address:
What is the best way to reach you regarding appointments and orders?: (You can pick more than 1)*

Phone CallTextEmail
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Vision Insurance:

(Please fill out using the Primary Subscriber's Information)
Vision Insurance (Select one of the following):*

CalOptima (through VSP)Davis VisionEyeMedSpecteraSuperior VisionVision Service Plan (VSP)Other
Primary Subscriber's Full Name:
If you are the Primary Subscriber, please enter "Self"
Primary Subscriber's Date of Birth:
Skip this field if you are the Primary Subscriber
Last 4 Digits of Primary Subscriber's Social Security Number:
Skip this field if you are the Primary Subscriber
Medical Insurance:

(Please fill out using the Primary Subscriber's Information)
Insurance Company:
Medical Insurance - NOT Vision
Subscriber ID:
Medical Insurance - NOT Vision; May also be referred to as "Member" or "Plan" ID. If you are insured by Kaiser Permanente, please enter your Medical Record Number
Group Number:
Medical Insurance - NOT Vision
Reason for Visit:*

Annual Exam for EyeglassesAnnual Exam for Eyeglasses and Contact LensesMedical Visit (Conjunctivitis, Stye, Irritation, etc.)Other
Do you smoke?:*

NoYes
Are you being treated for any medical condition(s)?:*

NoYes
If you answered yes, please list:
If unsure, enter "Unknown"
Please list any medications or supplements your are taking:*
If none, please enter "None" or "N/A"
Are you allergic to any medications, including eye drops?:*

NoYes
If you answered yes, please list:

Have you or any blood relatives been diagnosed with the following conditions?

Rows	Self	Father	Mother	Siblings	Grandparents
Diabetes
High Blood Pressure
High Cholesterol
Macular Degeneration
Glaucoma
Asthma
Lung Disease
Heart Disease
Thyroid Problems
Seasonal Allergies

Authorization:

I hereby give my consent to the doctors, staff and associates of Ikeda Optometry to provide eye care services to me and / or my family. I understand and agree that I am responsible for the balance of the account. I acknowledge that by presenting myself or my child as a patient, I consent for vision and medical care by Dr. John Ikeda and the staff of Ikeda Optometry. I hereby grant full authority to Dr. John Ikeda and respective assistants to administer and perform any and all drugs, treatments, tests, or diagnostic procedures to or upon me, which may be advised or necessary.
Responsible Party's Signature:
DateTime
Should be Empty:

New Patient Registration

Vision Insurance:

Medical Insurance:

Authorization: