Patient Name*

Prefix First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Occupation

Social Security #

Date of Birth

Age

Email*

Have you been examined here before?

Yes
No

Have you ever had a Dilated Eye Exam? If so, when?

Yes
No

Do you have frequent headaches?

Yes
No

Do you ever see double? (Two images, not just blurry)

Yes
No

Do you have dry eyes?

Yes
No

Do you see Flashing Lights or Floaters? (Circle which one)

Yes
No

Have you ever had an eye infection, injury or surgery?

Yes
No

Would you like information about Laser Vision correction?

Yes
No

Have you ever worn contact lenses?

Yes
No

Are you interested in contact lenses?

Yes
No

Personal Medical History

High Blood Pressure

Yes
No

Diabetes

Yes
No

Glaucoma

Yes
No

Cataracts

Yes
No

Crossed/Lazy Eyes

Yes
No

Family Medical History

High Blood Pressure

Yes
No

Diabetes

Yes
No

Glaucoma

Yes
No

Cataracts

Yes
No

Crossed/Lazy Eyes

Yes
No

List / Describe medications you are taking

List any Allergies

I authorize the release of information to determine liability for payment and/or obtain reimbursement by Contact Lens and Vision. I understand that if my account is not paid in full, I am responsible for the remaining balance and/or full amount and will be billed of the outstanding balance.

Signature

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Date