Dr William L Jones

Dr William L Jones

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New Patient Form

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Patient Details
Name*
First Last
Date of Birth*
Are You a Minor?
- No
- Yes
Legal Guardian Name
First Last
Contact Information
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Mobile Phone
OK to Contact Via Text Message?
Email
Enter Email Confirm Email
Preferred Contact Method
Do You Have an Emergency Contact?
- No
- Yes
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Demographics
Your Occupation
Gender
Marital Status
Race/Ethnicity
How Did You Hear About Our Office?
Who May We Thank for Referring You?
Insurance
- I have insurance
- I do not have insurance

Insurance Verification
Last Four Digits of Primary Insurance Holder's Social Security Number
Vision Insurance
Vision Insurance Provider
Vision Insurance Member Name
Vision Insurance Member ID#
Vision Insurance Member Date of Birth
Primary Medical Insurance
Name of Medical Insurance Provider
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
Secondary Medical Insurance
Name of Medical Insurance Provider
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

Exam History
When Was Your Last Eye Exam?
Height
Weight
Do You Currently Wear Glasses?
- Yes
- No
How Often Does Patient Wear Glasses?
- Constantly
- Reading / Computer
- Driving
- Leisure / Fashion only
Do You Currently Wear Contacts?
- Yes
- No
Current Contacts Brand
Current Contacts Prescription
Are You Interested in Contacts?
- Yes
- No
Reason for Your Visit
Name of Your Primary Care Physician
Medical History
Have you experienced, or been treated for, any of the following? Check all that apply.
Your Eye History*
- 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
- None
- Other
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
- None
- Other
Other Medical Conditions
Medical History
Your Medical History
Have you 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
- None
- Other
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
- None
- Other
Vitamins
Please indicate all recreational and over-the-counter vitamins.
- Aspirin
- Vitamin C
- Vitamin D
- Vitamin E
- Omega-E/Fish Oil
- Glucosamine
- Antihistamine
- None
- Other Vitamins
Current Medications
List all medications and conditions being treated.
Medication Drug Allergies
Please include food, tape, latex, and dyes.
Are you pregnant or have you recently been pregnant?
- Yes
- No
Do you smoke?
- Yes
- No
- Never
How Many Packs Per Day?
- 1
- 2
- 3
- 4
- 5 +
- Social
Do you consume alcohol?
- Yes
- No
How Many Drinks Per Week?
- 1
- 2
- 3
- 4
- 5 +
- Social
Name
This field is for validation purposes and should be left unchanged.