Submit the following New Patient Information Form now to speed up the check-in process on the day of your appointment. After completing the form, you will be given the opportunity to print the results to bring with you on appointment day. Don't have a printer? Don't worry... we'll have the info you submit waiting when you arrive!

Your appointment date:
Your appointment time:
About the Patient  
Last Name:  
First Name, Middle Initial:  
Street Address:  
City:  
State / Zip:  
Email:  
Home Phone:
Cell Phone:
Pager #:
Date of Birth:        
  Year:  
Sex:  
Social Security Number:  
Emergency Contact No.:  
Family Physician:  
Referred by:   Name or explain:
Patient's Employer:
Employer Address:
City:
State / Zip:  
Employer Phone: Ext.:
Ocular History
Cataracts:   Eye Trauma:   Floaters:
Glaucoma:   Eyelid Problem:   Tearing:
Retinal Disease:   Blurred Vision:   Dry Eyes:
Crossed Eyes:   Double Vision:   Eye Discharge:
Do you wear contacts or glasses?  
If yes, what type:
Medical History
Diabetes:   Kidney Disease:
Thyroid Disease:   Heart Disease:
Lung (breathing) Disease:   Cancer:
Neurologic (nerve) Disease:   High Blood Pressure:
Headaches:   Ulcers or Digestive Disease:
Other:  
Please list all previous eye surgeries and problems:  
Please list the names of all medications that you are currently taking:  
Please list the names of all medications to which you are allergic:  
If you are not sure of your insurance coverage, please refer to the toll-free 800 number on the back of your insurance card.
AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN
I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his services as described, realizing that I am responsible to pay non-covered services.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims.
ACKNOWLEDGEMENT
I hereby acknowledge that my electronic submission of this form constitutes an agreement to the terms described above.