If you are new or if you are a familiar face we need you to update your information. Please complete the following form before your eye examination.

Name

Prefix First Last

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Daytime phone*

Cell phone*

Email Address*

Communication preference*

Please let us know how you would like us to contact you. You can say All or chose one

Please let us know if you are bringing a translator with you. We need to know for social distancing.

Occupation

Referral source

Referral other

Insurance Company Name

Insured's name

First/last

Insurance Identification number

Group number

Insured's Date of Birth

Patient's relation to Insured

Secondary Insurance

Do you have secondary insurance?

Insured's name

First/last

Identification number

Group number

Insured's Date of Birth

Patient's relation to Insured

Why are you visiting us?

Do you wear Contact lenses?

Are you Diabetic?

Will you need to choose new glasses?

Do you need information about Vision Therapy and Neuro-Optometric Rehabilitation?

Signature

Date

New Patient Contact Form