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Step 1 of 2

  • Person being examined

  • MM slash DD slash YYYY
  • Person responsible for bill (if different from patient)

  • Person who carries insurance

  • MM slash DD slash YYYY
  • (assuming you are properly wearing your correction)
    Difficulty with distance vision
    Difficulty with near vision
    Family history of glaucoma
    Family history of blindness
    Family history of diabetes
    Family history of cataracts
    Significant eye pain
    Frequent headaches
    Ever had eye disease
    Ever had eye surgery
    Use any eye drops
    Ever worn eyeglasses
    Ever worn contacts
    Bothered by bright lights
    Permanent eye damage
  • MM slash DD slash YYYY
  • Your signature on this form will serve as "signature on file" for billing any insurance for you. This will allow your insurance payments to be made directly to our office. I understand that I will be responsible for any charges not covered by insurance.
  • MM slash DD slash YYYY