Contact Lens Form Name First Middle Last Suffix Are you already a patient in our office? Please remember to also fill in the contact form. Date of Birth* MM slash DD slash YYYY Email Address* Do you wear contact lenses Yes No What kind of contact lenses do you wear? Can you tell us the Brand name?How old are your current lenses? How often do you replace of dispose your contact lenses? What brand of solution do you soak your lenses in? What is your typical wearing schedule? In hours per day: What is your typical wearing schedule? In days per week: I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in changing or enhancing my eye color I am interested in a non-surgical method of vision correction I am interested in refractive laser surgery I don't have a spare set of contact lenses
