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PATIENT INFORMATION

Name

Address

Date of Birth

Home Phone

Cell Phone

Email

Preferred Contact Method

INSURANCE INFORMATION Primary Insurance Member's Name

Primary Insurance Member's Date of Birth

MEDICAL HISTORY Does the patient have any of the following:

Does the Patient have a family member with the following:

Does the Patient have a family member with the following:

Other health conditions

List all medications currently taking

List all known drug allergies

EYEWEAR HISTORY Has the patient ever had an eye exam?

Date of last exam

Name of previous eye doctor

Were glasses or contact lenses prescribed at that exam?

If yes, when is the correction worn?

What is the patient planning on getting at this visit?

How did you become aware of our office?

Before your first visit to our office, you may fill out our new patient form and submit. You may also download the form by clicking on: Medical History Questionnaire to bring with you to our office. Filling out your paperwork in advance is not a necessity, but may save you time at your visit. 

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