Allure Eye Clinic 


Patient Information
First Last Nickname
Address:
City: State/ZipCode
Medical Insurance 
In case the doctor finds medically related issues with your eyes, please provide your medical insurance to reduce your out of pocket costs.
Insurance Name:
Insurance ID:
Not Primary on Account: Not Primary

Primary Insured Information
Name: Last, First
Birthday:
Last 4 Digits of SSN:

Medical History
Please list any eye issues you're currently having:

History of Conditions

  You Family No
Diabetes     
Cataract     
Lazy Eye     
Glaucoma     
Computer Vision Syndrome     
Macular Degeneration     
Vitreous Detachment     
Retinitis Pigmentosa     
Retinal Detachment     
Color Blindness     

Pregnant Or Nursing?:

How often do you use a computer for work?:
Hobbies:

Submit Data