Greeley Eyecare Center
Secure Form
New Patient Form
Step
1
of
3
33%
Patient Details
Patient Name
*
First
Last
Patient Date of Birth
*
Is the Patient a Minor?
No
Yes
Legal Guardian Name
First
Last
Contact Information
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone
*
Mobile Phone
OK to Contact Via Text Message?
Yes
No
Email
Enter Email
Confirm Email
Preferred Contact Method
Primary Phone
Mobile Phone
Email
Do You Have an Emergency Contact?
No
Yes
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Demographics
Patient Occupation
Employer
Patient Gender
Select One
Male
Female
Other
Patient Marital Status
Select One
Single
Married
Divorced
Legally Separated
Widowed
Patient Race, Ethnicity
Select One
Caucasian
African American/Black
Hispanic/Latino
Asian
Middle Eastern
Pacific Islander
Native American/Alaskan
Other
How Did You Hear About Our Office?
Select One
Insurance Provider
Internet Search
Doctor Referral
Friend Referral
Website
Yellow Pages
Location
Other
Who May We Thank for Referring You?
Insurance
I have insurance
I do not have insurance
Insurance Verification
Last Four Digits of Patient's Social Security Number
Vision Insurance
Vision Insurance Provider
Vision Insurance Member Name
Vision Insurance Member ID#
Vision Insurance Member Date of Birth
Do You Have Secondary Vision Insurance?
Yes
No
Secondary Vision Insurance Provider
Secondary Vision Insurance Member Name
Secondary Vision Insurance Member ID#
Secondary Vision Insurance Member Date of Birth
Medical Insurance
Medical Insurance Provider Name
Medical Insurance ID#
Medical Insurance Policy or Group ID#
Medical Insurance Member Date of Birth
Medical Insurance Member Employer
Relationship to Medical Insurance Member
Spouse
Child
Do You Have Secondary Medical Insurance?
Yes
No
Secondary Medical Insurance Provider Name
Secondary Medical Insurance ID#
Secondary Medical Insurance Policy or Group ID#
Secondary Medical Insurance Member Date of Birth
Medical Insurance Member Employer
Relationship to Secondary Medical Insurance Member
Spouse
Child
Reason for Patient's Visit
Exam History
When Was Patient's Last Eye Exam?
Does Patient Currently Wear Glasses?
Yes
No
Does Patient Plan on Updating Eyeglasses Today?
Yes
No
How Often Does Patient Wear Glasses?
Constantly
Reading / Computer
Driving
Leisure / Fashion only
Does Patient Currently Wear Contacts?
Yes
No
Current Contacts Brand
Current Contacts Prescription
Is Patient Interested in Contacts?
Yes
No
Is Patient Satisfied with the Vision and Comfort of Current Contacts?
Yes
No
Name of Patient's Primary Care Physician
Is Patient Interested in Laser Vision Correction?
Yes
No
Optical & Medical History
Has patient experienced, or been treated for, any of the following? Check all that apply.
Eye Conditions & Disorders
Cataracts
Crossed Eye
Glaucoma
LASIK or RK
Lazy Eye
Macular Degeneration
Retinal Detachment
Blurry Vision (Near or Far)
Burning
Discharge
Double Vision
Dryness
Excess Tearing/Watering
Eye Infection
Eye Pain or Soreness
Floaters or Spots
Halos
Headaches
Itching
Light Flashes
Light Sensitivity
Redness
Sandy or Gritty Feeling
Other
Other Conditions & Disorders
Medical Conditions
AIDS/HIV
Allergies
Arthritis
Asthma
Blood/Lymph Disorder
Cancer
Diabetes
Ears, Nose, Throat Conditions
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorder
Seizures
Skin Conditions
Stroke
Thyroid Dysfunction
Other
Other Medical Conditions
Family History
Has any of patient's family members experienced, or been treated for, any of the following? Check all that apply.
Arthritis
Amblyopia
Stroke
Glaucoma
Thyroid Disease
High Blood Pressure
Diabetes
Cancer
Lupus
Kidney Disease
Macular Degeneration
Retinal Detachment
Cataract
Blindness
Other
Other Family History
Medications & Vitals
Vitamins
Please indicate all recreational and over-the-counter vitamins.
Aspirin
Vitamin C
Vitamin D
Vitamin E
Omega-E/Fish Oil
Glucosamine
Antihistamine
Other Vitamins
Current Medications
List all medications and conditions being treated.
Medication Drug Allergies
Please include food, tape, latex, and dyes.
Is Patient Pregnant or Nursing?
Yes
No
Does Patient Smoke?
Yes
No
Never
How Many Packs Per Day?
1
2
3
4
5 +
Social
Does Patient Consume Alcohol?
Yes
No
How Many Drinks Per Week?
1
2
3
4
5 +
Social
Phone
This field is for validation purposes and should be left unchanged.
