New Patient Forms

Patient Name

Address

Date of Birth

SS#

Marital Status

Sex

Cell Phone

Email

Home Phone

Alternate Phone

Employer

Occupation

Medical Insurance

Vision Insurance

PRIMARY Insurance Holder

Date of Birth

SS#

Relationship

Address

Cell Phone

Employer

Emergency Contact

Cell Phone

RACE/ETHNICITY

How did you hear about us?

Consent

I agree.

I hereby authorize Menard Eye Center to perform diagnostic and therapeutic procedures, if necessary for proper eye care.
I request that payment of authorized insurance benefits be made on my behalf to Keith Menard, O.D. for services rendered to me by that physician.
I give consent to be reminded for my appointment or of any new procedures or products by phone, mail, answering machine, text, or email.

Signature

Date

MEDICAL HISTORY

Patient Name

Date of Birth

Please fill out completely and to the best of your knowledge. This may not have to be required again for future visits. We will periodically ask if there are any changes.

Primary Care Physician

Pharmacy: name/location

Last eye exam: where/when

Medical conditions

*We can copy a list of your medications if needed*

Medications

Medication allergies

Have you worn vision correction in the past?

Glasses
Contacts
None

Eye surgery: type/doctor/when

Eye drops: name/frequency

Family history: Diabetes, glaucoma, macular degeneration, other

Current Tobacco user?

Yes
Smokeless Tobacco
Never
Quit

Complaints (examples: blurry vision, dryness, irritation, headaches, etc.)

Patient Information

Keith Menard, O.D.

MEDICAL HISTORY