Patient Welcome Form Welcome To Our Office Office LocationSelectGermantownFrederickName First Last Date Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SexFemaleMaleDate of Birth Date Format: MM slash DD slash YYYY OccupationPhoneWork PhoneEmployerEmail Whom may we thank for referring you?InsurancePolicy ID #Policy Holder NameDate of Birth Date Format: MM slash DD slash YYYY Relationship to InsuredHave you ever worn glasses?YesNoHave you ever worn contact lenses?YesNoWorn previously but discontinuedDate of Last Exam Date Format: MM slash DD slash YYYY Your reasons for visiting our office today: General Check Up Lost or Broke Glasses Want New Glasses Blurry Distance Blurry Near Vision Headaches Want Contact Lenses Interested in Lasik Dry Eyes Your General and Ocular Health High Blood Pressure Heart Disease High Cholesterol Diabetes Allergies Retinal Disorder Floaters/Flashes Cataracts Strabismus Glaucoma Amblyopia Eye Injury Eye Surgery HIV Family History of AboveFamily Physician Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Current MedicationsAllergies to MedicationsI agree to pay all charges not covered by my insuranceSignature
