For Faster service, please complete the following form prior to arriving at our office.

Appointment Date

Patient's Name (please print)*

First Middle Last

Birth Date

Gender

Address*

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

Home Number*

Please provide a telephone number, with area code, so we can contact you.

Cell Phone

Work Phone

Email Address

Please provide your email address.

Employer

Occupation

Employer Contact

Phone Number

Date of Last Eye Exam

Name of Previous Eye Doctor

Personal medical Information: Do you have problems with any of these systems? If Yes, please check box.

Are you in good health?

Any allergic reactions to medications or other substances?*

If yes, please list________________________________________________

Name of general physician

If yes, please check box.

Please explain any boxes you have checked.

Do you use other substances?

Do you have family history of any of the following? If yes, please check box.

Please explain any boxes you have checked

Do you have any of the following? If yes, please check box.

Any eye problems at this time? Please explain

Are you interested in laser vision correction?

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Date

Phone

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Medical History Record