Appointment Request
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New Patient Form

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Name*
Date of Birth*
Last Medical Exam Date
Last Eye Exam Date
Gender

Contact Information

Address

Insurance

Date of Birth
Date of Birth
Date of Birth

Optical History

Do you wear glasses?
Do you wear contact lenses?
Would you like to be evaluated for contacts? (Additional fee may apply)
What is the reason for today's visit?
Check all that apply.

Dilated eye exam

As a part of your comprehensive eye exam, your eyes will be dilated. If you choose NOT to be dilated you may defer by initialing and letting the doctor and staff know. You can choose to be rescheduled for the dilation portion of the exam on a day of your convenience.
Please choose one

Social History

Tobacco
Alcohol
Narcotics
Nursing or pregnant (if applicable)

Medical History

Past Ocular History
Constitution
Ears, Nose, Throat
Neuro
Psych
Cardio
Respiratory
Gastrointestinal
Genitourinary
Musc/Skel
Integumentary
Endocrine
Diabetes
Hem/Lymph
Allergic/Immunologic

Medication

Family History

Cancer
High blood pressure
Diabetes
Stroke
Macular Degeneration
Glaucoma
Cataracts
Other

Financial Responsibility - Medical Information Release - HIPPA

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand I am financially responsible for any balance. I authorize Maui Optometry or insurance companies to release any information required to process claims. I also acknowledge that I have been given notification of my HIPM privacy rights.
Date
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By signing below I confirm that my information is CURRENT and there have been NO CHANGES to my medical conditions or insurance
Date
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