New Patient Forms | Dr. Luna Xu

New Patient Registration Form

You can fill out this form on screen and print it, then bring it with you to your appointment. If you have any questions, please call us at (718) 442-2711.

For your privacy: this form asks for medical and insurance details, so it is not submitted online. Please print it and bring it to your visit, or complete it at the office when you arrive. We are happy to help you fill it in person.

Personal Information

Full Name *

Date of Birth *

Address *

Phone Number *

Email Address *

Insurance Information

Insurance Provider

Policy / Member ID Number

Group Number

Subscriber Name (if different from patient)

Medical History

Do you have any of the following? (Check all that apply)

Diabetes High Blood Pressure Glaucoma Cataracts Macular Degeneration Dry Eye Syndrome Retinal Detachment Other

Additional Medical History / Notes

Current Medications

Please list all current medications (including over-the-counter and supplements)

Do you have any allergies? (medications, latex, etc.)

Reason for Visit

Reason for Visit *

Please describe your symptoms or reason for visit in detail

Note: Print this form and bring it with you, or complete the paperwork at the office. Please arrive 15 minutes early if you need to complete it here. If you have any questions, please call us at (718) 442-2711.

Nothing is sent from this page — your details stay on your device until you print.