KOP Family Eye Care New Patient Form
Patient Name *
Address *
(Including city, state, and zip code)
Home Phone
Work Phone
Cell Phone
Birthdate *
MM
/
DD
/
YYYY
Social Security Number
(Last 4 digits)
Occupation
Email address
Vision Insurance Carrier
Health Insurance Carrier
Primary Care Physician
Primary Care Physician Phone
Sports/Hobbies
Referred by
Previous Eye Doctor
Date of Last Eye Exam
(approximation)
MM
/
DD
/
YYYY
Reason For Visit
Eyeglass wear *
Contact Lens wear *
If you currently wear contacts, please list your left and right contact lens brand and prescription.
(Please make sure to include all prescription information)
List any previous ocular surgeries, diagnoses, or injuries
List any current ocular diagnoses
(glaucoma, cataracts, etc)
Are You Interested in Laser Vision Correction?
Clear selection
Ocular Family History
(Glaucoma, macular degeneration, or any other ocular issues)
Family Health History
List major illness in the family.
Personal Health History
List personal major illness.
Do You Smoke? *
Medications, including over the counter and supplements
(list name, dosage, and condition)
Allergies
(include drug and environmental)
Submit
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