Patient Welcome Form

Office Location

Name

First Last

Date

Address

Street Address Address Line 2 City State ZIP Code

Sex

Date of Birth

Occupation

Phone

Work Phone

Employer

Email

Whom may we thank for referring you?

Insurance

Policy ID #

Policy Holder Name

Date of Birth

Relationship to Insured

Have you ever worn glasses?

Have you ever worn contact lenses?

Date of Last Exam

Your reasons for visiting our office today:

Your General and Ocular Health

Family History of Above

Family Physician

Prefix First Last Suffix

Current Medications

Allergies to Medications

I agree to pay all charges not covered by my insurance

Signature