New Patient Paperwork

First name

Last name

Address

City, State, Zip Code

Phone

Email

SSN

Birthday

Month

Day

Year

List Previous Eye Surgeries/Dates They Occurred

Do you wear Glasses?

YES, I wear Glasses

NO, I don't wear glasses

When were your glasses last changed? How long have you been wearing glasses?

If any of the questions below do not apply to you, put a N/A in the text box!

Last Eye Exam?

Preferred Pharmacy? Please include address or cross streets!

Primary Care Physician? Please include the practice and location!

List your current prescription medications and supplements with dosage

Are you taking any eyedrops? If so, what kind, and how many times per day?

Do you have any allergies to medicines?

Please list any prior surgeries

Any Medical problems that aren't listed above.

Is there anything else you would like to add?

Thanks! We appreciate the time you spent filling out this questionnaire, and we look forward to you visit!

Financial policy acceptance

I have read and agree to the financial policy

Please Upload a photo of the front your driver's license

Please Upload a photo of the front of your current insurance card

Please Upload a photo of the back of your current insurance card

How did you hear about us?