.
Dr. Mija J Lee
250 W Highway 67
Duncanville, TX 75137
972-572-9555
PATIENT DEMOGRAPHICS/INSURANCE FORM
Today's Date:
Open the calendar popup.
Patient's First Name:
 
M.I:
Last Name:
 
Date of Birth:
Open the calendar popup.
 
Sex:
Social Security #
- -
Race:
Ethnicity:
Preferred Language:
Address:
City:
State:
Zip:
Preferred Contact Method:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
 
Confirm Email:
 
Employment Status:
Employer:
Occupation:
Student Status:
Marital Status:
Spouse Name:
Spouses Employer:
Where you referred by a Doctor?
Referring Doctor:
How were you referred to our clinic?
Emergency Contact: Name:
Relation to Patient:
Emergency Contact Home Phone:
Emergency Contact Work Phone:
Responsible Party:
Responsible Party Phone Number:
Responsible Party Address:
Responsible Party City:
State:
Zip:
INSURANCE
Primary Insured Name:
Primary Insured's Employer:
Primary Insured DOB:
Open the calendar popup.
Primary Insured's SSN:
- -
Patient Relationship to Primary Insured:
Medical Insurance:
Member ID/SS#:
Group Name or #:
Vision Insurance:
Member ID/SS#:
Group Name or #:
Secondary Insurance:
Member ID/SS#:
Group Name or #:
Secondary Subscriber Name:
Secondary Subscriber DOB:
Open the calendar popup.
Patient Relationship to Secondary Ins. Subscriber:
Self Pay:
Self Pay Patients must pay in full at the time of the service. Insurance will be verified and accepted, however, the co-pay, deductible and/or any non-covered charges must be paid in full at the time of the visit.
VISUAL AND MEDICAL HISTORY
Reason for today's visit?
Date of last eye exam?
Open the calendar popup.
By whom?
Do you presently wear?
If not currently wearing contacts, are you interested in trying them today?
If you wear contact lenses, do you know what type or brand?
Are your contacts comfortable?
How old are your glasses?
How old are your contacts?
Name of your Medical Doctor:
Dr's Phone:
Are you currently taking any medications?
(including oral contraceptives, aspirin, otc and/or herbal meds)
If so please list:
  Type Brand Name Generic Name Strength Dose Route Frequency Started On
Do you have allergies to any medications?
If so please list:
  Type Allergy-Medication Name Reaction Details Severity