New Patient Form
Information gathered is for insurance and communication purposes only. It will never be shared or sold.
Name
*
First Name
Last Name
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
*
example@example.com
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Marital Status
Married
Single
Sex
M
F
SS#
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Responsible Party
Self
Other
Other
Primary Insurance
ID#
GRP#
PPO
HMO
Medi-Cal
Medicare
Secondary Insurance
ID#
GRP#
PPO
HMO
Medi-Cal
Medicare
Vision Plan
VSP
Eyemed
Spectera
Davis
MES
Other
I authorize payment of medical or vision benefits and release of medical information to Ilan Hartstein, M.D inc.. I agree to pay any amount approved but not paid for by my insurance eg: deductible, co-insurance, copay or non covered services. I acknowledge that I have received a copy of the notice of Privacy Practice.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Comprehensive History
What is your chief complaint / reason for visit?
Previous Eye History
None
Previous Medical History
None
Allergies to medications
Yes
No
If yes, please list allergies:
Current medications or drops
None
Medical History / System Review
Do you have or have you had any of these conditions? Please check only those that apply
Asthma
Stroke
Thyroid
Cholesterol
High Blood Pressure
Diabetes
Cancer
None of the above
Other
Family History
Glaucoma
Blindness
Retinal Disease
Diabetes
None
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: