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Call: 618-744-7555
Text Only: 877-415-0435
Now located at Frank Scott Parkway West and Town Hall Rd by Belleville West High School
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New Patients

New Patient Form

"*" indicates required fields

Please complete the information below and submit the form online or, if you prefer, print out the form after full or partial completion and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

MM slash DD slash YYYY
Name*
Address*
Date of Birth*
Gender

Please provide your medical insurance information.
This should be located on your insurance card
if applicable
if applicable
Please provide your vision insurance information. State None, if no vision insurance.
Please provide your email address.
Hav you ever worn:*

Medications

You can also bring a list of medications with you if needed.
List any medications you take including oral contraceptives, aspirin, OTC medicines, etc.:
Have you had your flu shot in the last 12 months?*

Social History

This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer. Please check the box below of you prefer to discuss with the doctor instead.
Do you participate in any of the following activities?*
Do you use tobacco products?*

Family History

Family History: (Parents, Grandparents, Siblings)*

Medical History

Have you had problems with weight loss or weight gain?*
Are you Pregnant or Nursing?*
Integumentary:*
Neurological:
Endocrine:*
Ears, Nose, Throat, Mouth:*
Respiratory:*
Vascular, Cardiac:*
Genitourinary:*
Musculoskeletal:*
Lymphatic/Hematologic:*
Psychiatric History:*
Do you Have any Allergies to Medications?*
Allergies:*
Do you have any history of Cancer?*
Any Eye Issues you are having:*
Do you see any other specialists for any eye related issues?*
Injuries/Surgeries/Hospitalizations*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.