New Patient Information Form

Vision and Medical History

Name *

Address *

Home Phone *​​​​​​​

Daytime Phone *

Cell Phone *

Email *

May we send you a text message for appointment reminders, arrival of glasses and/or contact lenses? *

Date of Birth? *

Social Security Number (last 4 digits only)? *

Sex *

Marital Status *

Emergency Contact

Relationship

Emergency Contact Phone Number

Medical Insurance

Vision Insurance (if applicable)

How did you hear about our office?)

Employer (or school)

Occupation (or grade)

Demographic History

Communication Preferrence

Preferred Language

Race *

Ethnicity *

Your Examination Needs

Your eyewear/contact needs

Medical History

Current Vision Assistance: (Please check all that apply)

Do you have any of the following: (check all that apply)


  • Medical History

  • Ocular History

Please describe any eye injuries that you have had. If no injuries, please put 'none' in the box. *

List any eye surgeries you have had

Are you currently pregnant or nursing?

Please list all prescriptions and over the counter medications you are taking.

Please list any present or past eye drops.

Please list all allergies (medications, food, environmental).

Family and Social History

Do any of your family members have the following? (Please check all that apply)

Do you smoke? *

Do you drink alcohol? *

Medical/Eye Health Information

Name of Physician

Phone Number of Physician

Date of Last Visit

Pharmacy Name

Pharmacy Number

Last Eye Examination Information

Date of Last Eye Exam

Name of Doctor

Office Name and Phone Number

Download & Print

Please bring this form with you to your appointment.
Optomap/Dilation & Enhanced Testing Form - Download

*

I hereby give my consent to Dr. Anderson to provide eyecare services for me and/or my family and to obtain records from my current and/or previous doctors. I also authorize the release of information and payment of vision/medical benefits, if I choose to use an insurance plan for which the doctors are providers.

Today's Date *

Signature *


First and Last Intials *