New Patient Form

New Patient Form

Patient Information

Name
Address
Cell Phone Number
Daytime Phone Number
Email Address
Gender
Date of Birth
Social Security Number (last 4 digits only)
Race/Ethnicity/Language
Marital Status
Employment Status
Employer
Occupation
How were you referred to our office?
Communication Preference?

Eye History

When was your last eye exam?
Where did you get your last eye exam?
Do you wear glasses?
Do you wear contacts? Do you know what brand?
Please check any current symptoms you experience
Have you or a family member experienced or been treated for any of the following?
​​​​​​​
Cataracts
Crossed Eye
Glaucoma
LASIK or PRK
Lazy Eye
Macular Degeneration
Retinal Detachment

Medical History

When was your last physical exam?
Who is your primary care physician?
Do you drink alcohol?
Do you use tobacco products?
Do you wear contacts? Do you know what brand?
Have you or an immediate family member experienced, or been treated for any of the following?
​​​​​​​
AIDS/HIV
Allergies
Arthritis
Asthma
Blood/Lymph Disorder
Cancer
Diabetes
Depression/Anxiety
Ears, Nose, Throat Condition
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorder
Seizures
Skin Conditions
Stroke
Thyroid Dysfunction
Please list any other medical condition not listed above.
Please list all prescription and over the counter medications you take.
**Upload a digital list of medications.
Please list all drug allergies you have.

Insurance Information

**Please bring all insurance cards with you to your appointment**
Vision Insurance Name
Vision Insurance Member Name
Vision Insurance Member ID#
Vision Insurance Member Date of Birth
Primary Medical Insurance Name
Primary Medical Insurance Member Name
Primary Medical Insurance Member Date of Birth
Primary Medical Insurance ID#
Primary Medical Insurance Policy/Group #
Primary Medical Insurance Member Employer
Your relationship to primary member?
Do you have a secondary Insurance?
If you have any additional comments you would like to add, please enter them here:
admin 08:00 AM - 05:00 PM 08:00 AM - 05:00 PM 08:00 AM - 05:00 PM 08:00 AM - 05:00 PM 08:00 AM - 05:00 PM optometrist # # # 9132708598 18208 W. 119th St Olathe, KS 66061 9132618328 8:00 AM - 7:00 PM 8:00 AM - 7:00 PM 8:00 AM - 6:00 PM 8:00 AM - 6:00 PM 7:00 AM - 4:00 PM 8:00 AM - 1:00 PM Closed 9132706017 33321 Lexington De Soto, KS 66018 9135831934 Closed 9:00 AM - 6:00 PM Closed Closed 9:00 AM - 5:00 PM Closed Closed