Patient Paperwork

Today's Date *

Office Location *

Patient Information

Patient Name *

First

Middle

Last

Mailing Address *

Address Line 1

City

State

Zip Code

Phone # *

Email *

Emergency Contact *

First

Last

Emergency Contact Phone # *

Relationship

Employer

Employer Phone #

Date of Birth *

SSN#

Sex

Male
Female

Marital Status

Disabled or Retired

Yes, Disabled
Yes, Retired

Race

Ethnicity

Language

If Policy Holder is other than Patient, Please Complete

Policy Holder Name

First

Middle

Last

Policy Holder Mailing Address

Address Line 1

City

State

Zip Code

Policy Holder Date of Birth

Policy Holder SSN#

Policy Holder Phone #

Policy Holder Email

If Patient is a Minor, Guarantor Information

Guarantor Name

First

Middle

Last

Guarantor Mailing Address

Address Line 1

City

State

Zip Code

Guarantor Date of Birth

Guarantor SSN#

Guarantor Phone #

Guarantor Email

than Primary Holder

Insurance Information & Medical History

Primary Care Practitioner

Insurance Carrier

Name of Vision Coverage (if applicable)

Phone

Group Number

Member ID

Eye Medications

Please List One Per Line

Other Medications

Please List One Per Line

Allergies

Please List One Per Line & Its Reaction. Leave Blank if None.

Medical Conditions

Please List One Per Line. Leave Blank if None.

List Any Surgeries & Date

Please List One Per Line

Smoking History

Alcohol Usage

Blood Sugar

Blood Sugar A1C

Date Taken