NEW PATIENT FORM

Complete your new patient paperwork at home and save time in the office!

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Day Phone *
Day Phone
Evening Phone *
Evening Phone
This information can help us to determine the best care for your eyes.
Insurance Info
If you do not have HEALTH insurance or VISION insurance, please type "None."
The next section will ask for your VISION insurance company name.
Eyeglass History
Do you wear glasses? *
What type of glasses do your own? *
Do you use a computer? *
If you wear eyeglasses, are there certain times when you would rather not?
If you wear eyeglasses, does your spare pair have your correct prescription?
Do your sunglasses have UV (ultra-violet) protection?
Are your sunglasses your current prescription?
Contact Lens History
Do you currently wear contact lenses? *
Have you ever tried to wear contact lenses? *
Are you interested in changing or enhancing your eye color? *
If you currently wear contact lenses, do your backup eyeglasses have your correct prescription?
Are you having any problems with your current contacts? *
Would you like to be evaluated for refractive laser surgery? *
Medical History
Date of last eye exam
Date of last eye exam