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new patients form

We Welcome New Patients. Save time when visiting Doctors Vision Center by completing your new eye care patient forms online. As with any professional medical office, we will need some initial information and your medical history to set you up as a new patient.  Prior to your visit, please fill out these forms, print and bring them with you to your appointment.

Patient and Responsible party information

First name *
 Last name *
 (Jr, Sr, etc)
 Nickname *
Address *

City *

State *

Zip

Home/Work #

 Soc sec #

Birthdate

Sex
 Male Female
Martial status
 S M D W

Email *

How did you hear about our office?

A. Preferred language:
  English   Spanish

B. Race:
  American Indian/Alaska Asian   Black/African American   Hispanic
  Native Hawaiian/Pacific Islander   White   Other

C. Ethnicity:
  Hispanic/Latino   Native Hawaiian/Other Pacific Islander   Not Hispanic or Latino

D. Communication Preferrence:
  Email   Phone   Postal

Do you have any questions about dry eyes, laser corrective surgery, vision therapy or any other medical concerns? If so, please list:

Are you member of Doctors Vision Center Group Vision Plan?
 Yes, I Am Yes, My Family Is No Don`t Know

If yes, Company name

Family member who has Group Vision Plan
 Self Parent Spouse

Employer
 Occupation *

Insurance information

Primary Insurance Co.

Policy holder

Relation to patient
 Self Spouse Child Other 		Secondary Insurance Co.

Policy holder

Relation to patient
 Self Spouse Child Other

Payment information

Payment Policy: Payment in full is expected at the time professional services are rendered and/or materials are ordered. We are happy to file forinsurance payment when applicable. A charge of 1.5% per month will be added to all accounts 30 days past due. Initial______

Failure to pay balances in the allotted time will result in patient incurring additional costs of collection including, but not limited to attorney or legal fees, collection agency fees and finance charges. Initial______

Your method of payment *
 Cash Check Credit Card

Acknowledgment

1. Payment policy: payment in full is expected at the time professional services are rendered and/or materials are ordered. We are happy to file for insurance payment when applicable. A charge of 1.5% per month will be added to all accounts 30 days past due 

2. If insurance is filed on my behalf, I authorize my insurance benefits to paid directly to Doctors Vision Center 

3. I agree that unless Doctors Vision Center and my insurer have a prior agreement, I am personally responsible for all non-covered services, co-pays and deductibles 

4. I authorize the release of medical information to insurance carriers or other physicians if it is deemed necessary by my optometrists for financial or consultative purposes 

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Patient Medical History Form

Last Name First Name Date

Family History

(please select all that apply)
 High blood pressure
 Relation:  		 Macular degeneration
 Relation: 
 Diabetes
 Relation:  		 Retinal detachment
 Relation: 
 Glaucoma
 Relation:  		 Cataracts
 Relation: 
 Other eye condition(s)
 Relation: 

Personal Medical Information

What is your general health?

Do you have problems with any of these systems? (please select all that apply)

 Gastrointestinal  Nervous  Mental
 Ears/Nose/Throat  Genitourinary  Endocrine (glands)
 Cardiovascular  Musculoskeletal  Blood/lymph
 Respiratory  Integumentary (skin)  Allergic/immunologic

Please explain

Diabetes No Yes Type:  Date of diagnosis:

Allergies No Yes Allergic to what?  What happens?

Other health problems

Have you had any operations? No Yes Kind?  When?

Do you use cigarettes/tobacco? 
Alcohol? 
Other substance(s)? 

Name of family doctor  Date of last physical 

Current medication(s)

Personal Eye Information

Last eye doctor seen  Last eye exam date 

Have you had any operations? No Yes
Type  Date Have you had an eye injury? No Yes
Type  Date

Have you been told you have:

Cataracts?  No  Yes
Glaucoma?  No  Yes
Macular Degeneration?  No  Yes

Other eye problems? Describe

Do you wear glasses? No Yes
Contact lenses?  No Yes Type 

With your glasses on, are you bothered by:
 Sunlight  Night Glare  Dry Eyes  Progressive
 Itching  Headaches  Distance Vision  Reading Vision
 Double Vision  Foreign Body
      Sensation 		 Excessive
      Tearing

Do you have questions about:
 Refractive Laser Surgery
 New Contact Lenses
 Vision Related Learning Problems

Whom may we thank for referring you?

DO NOT WRITE IN THE SPACE BELOW

Family Social History History Reviewed by
Orientation/ Affect Date Reviewed
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