New Patient Form

Envision Eye Care

General Information

Patient Name

First

Last

Address

Street Address

Address Line 2

City

State

ZIP Code

Primary Phone

Mobile Phone

Email

Confirm Email

Demographics

Date of Birth

Insurance Information

Last Four Digits of Social Security Number

Vision Insurance Provider

Vision Insurance Member Name

Vision Insurance Member ID#

Vision Insurance Member Date of Birth

Medical Insurance Provider

Medical Insurance ID#

Medical Insurance Policy# / Group ID#

Medical Insurance Member Date of Birth

Medical Insurance Member Employer

Your Relationship to Medical Insurance Member

Self Spouse Child

Exam History

Last Eye Exam

When was your last eye exam?

Currently Wear Glasses?

Yes No

Currently Wear Contacts?

Yes No

Current Contacts Brand

Current Contacts Prescription

Reason for your Visit?

Optical & Medical History

Have you experienced, or been treated for, any of the following? Check all that apply

Medications & Vitals

Current Medications

List all medications and conditions being treated.

Medication Drug Allergies

Please include food, tape, latex, and dyes.

Are you pregnant or nursing?

Yes No

Do you smoke?

Yes No

Have you ever smoked?

Yes No

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