New Patient

New Patient Intake


Please complete all sections to ensure the highest quality of care.

Patient Information

First Name

Last Name

Date of Birth

Gender

Street Address

City

State

Zip Code

Phone Number

Email

Insurance Information

Vision Insurance Carrier

Subscriber ID #

Medical Insurance Carrier

Subscriber ID #

Primary Insured Name (If different from patient)

Eye Health History

Reason for today's visit:

Do you currently have:

Ocular History:

General Health

Do you have any of the following?

Current Medications (List all)

Allergies (Medication or Environmental)

Visual Lifestyle

Hours per day on a computer/phone?

Do you wear Contact Lenses?

Hobbies / Visual Demands (e.g., Piano, Golf, Night Driving)

I certify that the information I have provided above is correct. I authorize Westwood & Montrose Eye Center to bill my insurance on my behalf. I understand that I am financially responsible for any balance not covered by my insurance carrier.

Patient/Guardian Signature

Date

TEXT FOR APPT
Los Angeles (310) 234-8900 Montrose (818) 330-7555