Online Patient Form

Patient Information

Title	First	Last	MI	Suffix	Nickname
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State:	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 TX UT VT VI VA WA WV WI WY	Zip Code:

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		Occupation
Sex	Male Female	Employment Status	Employed Full-Time Student Part-Time Student
Marital Status	Annulled Divorced Domestic partner Interlocutory Legally Separated Married Never Married Widowed	Employer / School Name
Misc/Guardian		How did you hear about us?	Google Facebook or Instagram Yelp Glasses Brand Website Friend or Family Word of Mouth Walking/Driving By Radio TV Magazine Existing client

Billing Information

Is The Billing Address the Different? Yes

Title	First	Last	MI	Suffix
Mr. Mrs. Ms. Dr. Rev.

Address:
City:		State:	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 TX UT VT VI VA WA WV WI WY	Zip Code:
Home Phone:
Work Phone:

Frame Styling Questionnaire

Glasses Preferences

The more detail you give us about your likes, dislikes, style, etc. the more tailored our selection will be for you. We are here to find you the best possible fit!

What do you LIKE about your current glasses? (I.e. color, shape, style, material, fit, weight, vision, etc.)

What do you DISLIKE about your current glasses? (I.e. color, shape, style, material, fit, weight, vision, etc.)

How Would you Describe your Personal Style? Classic Modern Vintage Artsty Minimalist Fun Funky Other

Is there anything you absolutely don't want?

Lenses

We consider various factors when making lens recommendations. The more we know about how you spend your days and expect your glasses to function for you, the better our recommendation will be.

What is your occupation or how you spend the majority of your days?

What type of lenses do you currently wear? Single Vision (ie Distance, reading, or computer) Progressive (multifocal with no line) Bifocal/Trifocal (multifocal with a line)

Are you looking for glasses, sunglasses, or both? (Our multiple pair discount is sweet!)

Glasses Sunglasses Both

Do you currently struggle with any of the following?

None Using a computer for long periods of time due to the way your lenses work Glare with nighttime driving Glare with daytime driving Eye Strain/fatigue

What indoor hobbies do you enjoy?

What outdoor hobbies do you enjoy?

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