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Welcome Form

Thank you for choosing our office for your eyecare needs! We’re glad to help if you have questions

All Patient Information is Confidential

Name(Required)
MM slash DD slash YYYY
Address(Required)
Text OK?:(Required)
MM slash DD slash YYYY
Gender(Required)
Marital Status(Required)
Preferred Language(Required)
Race (optional)

Insurance Information

If you are using insurance, we need a copy of your medical and vision cards. We provide treatment for both medical eye conditions as well as comprehensive vision care.
Primary Member’s Name:
Primary Member’s Name:

Please Fill Out Both Sides

Health History

Do you have any of the following?
AIDS/HIV(Required)
Type 1 Diabetes(Required)
Alzheimer’s Disease(Required)
Type 2 Diabetes(Required)
Arthritis(Required)
Cataracts(Required)
Autism Spectrum Disorder(Required)
Dry Eye(Required)
Cancer(Required)
Eye Injury(Required)
COPD(Required)
Eye Surgery(Required)
Developmental Delays(Required)
Epilepsy or Seizures(Required)
MM slash DD slash YYYY
Heart Disease(Required)
Glaucoma(Required)
High Blood Pressure(Required)
Lazy Eye(Required)
High Cholesterol(Required)
Macular(Required)
Kidney Disease(Required)
Degeneration(Required)
Lupus(Required)
Turned Eye(Required)
Osteoporosis(Required)
Do you use tobacco?(Required)
Rheumatoid Arthritis(Required)
Are you pregnant?(Required)
Stroke(Required)
Are you allergic to any of the following?
Thyroid Disease(Required)
Please check if any of the following family members have these conditions:
Do you currently wear Glasses?(Required)
Do you currently wear Contacts?(Required)
Are you interested in being fitted for Contact Lenses?(Required)
Are you renewing your contact prescription today?(Required)