New Patient Form

Thank you for providing your medical history. If you have any questions, please call our Patient Care Coordinators at 401-438-4447. Please bring your eyeglasses to your exam.

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(Note: When we call to confirm your appointment, we will ask for your Social Security Number and Insurance Plan/Numbers.)

Name

Date of Birth

Age

Address

Home Phone #

Work Phone #

Fax #

Occupation/Employer

Who recommended us?

Spouse:

Children:

For us to best understand your visual and eye safety needs, it is helpful for us to know your hobbies and interests. Please list:

The following questions help us consider your entire health picture in conjunction with that of your entire body health and lifestyle.

Did/Do any of the following symptoms or conditions apply to you?

	Light Sensitive		Eyes Burn/Itch
	Eye Strain		Work on Computer
	Eye Fatigue when reading		Headache
	Lazy Eye		Eye Injury
	Floaters/Spots		Flashes of Light
	Double Vision		Blurred Vision
	Use Eye Drops		Interested in Contacts?
	Change Eye Color?		Smoker
	High Blood Pressure		Heart Disease
	Thyroid		Diabetes
	Arthritis		Allergies
	Sinus		Other

Please list any medications you are currently taking:

Many eye and systemic (body) diseases can occur in families.

Did/Do any family members have:

	Glaucoma		Cataracts
	Blindness		Macular Degeneration
	Lazy Eye/Eye Turn		Diabetes
	High Blood Pressure		Heart Disease
	Cancer		Thyroid
	Arthritis		Other

Family Physician

Address

Last Checkup Date

Medication Allergies?

Do you regularly:

	Wear UV Blocking Sunglasses?		Do some cardiovascular exercise?
	Drink 4-6 glasses of water a day?		Avoid Red Meat and Fatty Food?
	Eat Fruits, Grains, & Veggies?		Take Vitamins or Anti Oxidants?
	Wear a Seatbelt?		Avoid Alcohol?
	Use Safety Glasses?

When was your last Eye Exam?

When was your last Dilated Exam?

Doctor's Name?

Primary Reason for this Visit?

By submitting this information, you allow the Vision Care Center and its agent to release any medical records necessary to process insurance claims on your behalf. You also verify that the inforomation entered on this form is true to the best of your knowledge.

Payment is due at the time of visit.
A minimum deposit of 50% is due prior to ordering eyewear.