Date

Name

First Last

How did you hear about Eye Services?

Date of last vision exam?

With whom?

Briefly explain the reason for your visit

Do you wear eye glasses

Yes
No

Are you interested in glasses?

Yes
No

Type of lenses

Do you wear contact lenses?

Yes
No

Type of lenses

Are you interested in contact lenses

Yes
No

Type of lenses

Are you interested in surgery to reduce or eliminate your dependency on glasses and/or contact lenses?

Yes
No

Please answer the Health Questions below by checking either Yes or No

	Yes	No
Diabetes
High Blood Pressure
Thyroid Problems
Neurological Problems
Kidney Problems
Lung/Asthma Problems
Pregnant (currently)
Hay Fever
Bleeding Tendencies
Sinus Problems
Headaches
Stomach Problems
Heart Abnormalities
Cholesterol
Skin Disorders
HIV/AIDS
TB/Pneumonia
Hepatitis/Pneumonia
Cancer
Arthritis
Prostate Problems
Tobacco use
Alcohol use

List any current medications:

Eye drops

List any allergies to medications

Primary care physician

Family History

Have you had any eye injuries or eye surgeries? If yes please explain

Have you had any general surgeries? If yes please expain

Have you been dignosed with any of the following?

Insurance Information

Name

First Last

Sex

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone

Email

Patient Date of Birth

Social Security Number

Occupation

Name of Employer

Special Visual Demands (Work or Hobbies)

Do You Have Vision Insurance

Yes
No

Do You Have Medical Insurance

Yes
No

Primary

Primary Vision Insurance

Medical Insurance

Name of Policy Holder

Policy Holder D.O.B.

Relationship to Policy Holder

Policy Holder Social Security

Work Phone

Employer of Policy Holder

Secondary

Second Vision Insurance

Second Medical Insurance

Name of Policy Holder

Policy Holder D.O.B.

Relationship to Policy Holder

Policy Holder Social Security

Work Phone

Employer of Policy Holder

In Case of Emergency

Emergency Contact

Phone

I acknowledge that I have received a copy of Eye Services Notice of Privacy Practices.

Please Sign

I authorize the release of any medical information necessary to process insurance claims and request payment to either myself or the party who accepts assignment. I state that the information on this document is correct to the best of my knowledge. I permit a copy of these benefits to myself or the party who accepts assignments.

Signature

Date

	Yes	No
Macular Degeneration
Cataracts
Diabetes
Blindness
Glaucoma
Strabismus (lazy eye)
Retinal Problems

	Yes	No
Macular Degeneration
Retina Problems
Cataracts
Strabismus (lazy eye)
Diabetes
Glaucoma
Serious Eye Disease

New Patient Form

Patient Registration Form- new

Insurance Information

Primary

Secondary

In Case of Emergency

Please Sign

Eye Services of Jackson