Patient Welcome Form Welcome To Our Office Office LocationSelectGermantownFrederickName First Last Date 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 MM slash DD slash YYYY Occupation PhoneWork PhoneEmployer Email Whom may we thank for referring you? Insurance Policy ID # Policy Holder Name Date of Birth MM slash DD slash YYYY Relationship to Insured Have you ever worn glasses?YesNoHave you ever worn contact lenses?YesNoWorn previously but discontinuedDate of Last Exam 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 Above Family Physician Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Current Medications Allergies to Medications I agree to pay all charges not covered by my insuranceSignature
