Untitled Form

Demographics

Title First Last MI Suffix Nickname Mr. Mrs. Ms. Dr. Rev. Address: City: State/ZipCode TX AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN UT VT VI VA WA WV WI WY Home Phone: Work Phone: Other Phone: Alerts: Cell Phone: Preferred Contact Method: Home Phone Work Phone Cell Phone Other Phone Text Message Email SSN Email Birthday mm/dd/yyy Occupation Sex Male Female Employer/School Name




General Information

How did you hear about us?

Please list your hobbies and activities

Main reason for your visit today?

Last Eye Exam

Do you use any eyedrops?

How many hours do you spend at the Computer?


Check if you have had or currently experience any of the following:

Eye infection, injury, or surgery?
Head Injury?
Flashes of Light
Frequent Headaches?
Double vision?



Additional Notes

Allergies

Medications


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