New Patient Form

Name

First Last

M
F

Date of Birth

Health Card #

VC

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Email Address

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How did you hear about us?

When was your last eye exam?

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Who was the eye doctor?

Reason for Today’s Visit

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Your Medical History

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Please Specify

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List of Medication

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List of Allergies

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Family Eye/Medical Problems

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Your Eye History

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Do You Use

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Do You Currently Have

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Any other comments?

INSURANCE INFORMATION

Primary Insurance

Company

Plan Member

Policy

Member ID

Secondary Insurance

Company

Plan Member

Policy

Member ID

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Additional Information

Head injury/stroke/other

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Date of loss

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Car accident
Stroke
Concussion

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Tests/Treatments

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Please Specify

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Eye-Hand Coordination

Poor hand writing
Difficulty reaching for objects
Reverses/ omits letters
Difficulty catching balls

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Driving

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TV/ Distance Vision

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Please Specify

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Lighting and Glare

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Please Specify

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Reading

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Please Specify

Working/Work

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Where do you work

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Please explain work done before the loss and after the loss. Include when or if you expect to return to work.

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Explain why you cannot work or if your work is limited.

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Academic/School

Do not go to school
In school

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Please explain any difficulties

Adult Intake Online Form

New Patient Form

INSURANCE INFORMATION

Primary Insurance

Secondary Insurance

Additional Information

Head injury/stroke/other

Working/Work

Thompson Optometry