Name(Required)

First Last

Date of Birth.(Required)

Mailing Address(Required)

Street Address City State ZIP Code

Home Phone

Cell Phone(Required)

E-mail Address

(used for some insurance billing)

Responsible party & relationship if patient is a dependent

How did you hear about us? (Examples: walk-in, referral, internet search, previous Costco exam, insurance)

Do you have a preference as to which doctor you see? (Choose no preference if you want the most appointment scheduling options)(Required)

Approximate date of last eye exam?

Location of last eye exam (write "this office" if last seen here or write the name of the clinic you were last seen at if seen elsewhere)?(Required)

Main purpose of today’s visit?(Required)

Do you currently wear glasses?(Required)

Do you currently wear contact lenses or have you worn contact lenses in the past?(Required)

Are you interested in wearing contact lenses and would be a new wearer that would need a longer office visit for training on how to insert and remove contact lenses? (Write "not interested" if you are not interested in contact lenses or "currently wear" if you currently wear contact lenses)(Required)

Have you had or are you interested in Lasik vision correction?(Required)

Ocular Health – please check any of the following that apply to you or click “none” if none apply(Required)

Please list medications you are taking and what they are being taken for. If you are not taking any medications, please type "None"(Required)

Please list any significant medical conditions not listed above. If you have none, please type "None"(Required)

Please list any medications that you are allergic to. If you have no allergies, please type "None"(Required)

Family History – please check any of the following that are in your direct bloodline(Required)

Diabetes

Glaucoma

Macular degeneration

Blindness

None

Other

Patient/Guardian’s Signature (check HIPAA statement above)(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.