New Patient Form

New Patient Paperwork
*Indicates Required Fields

Patient Information

Lifestyle Questions

Do you...(check all that apply)

work at a computer? think you might benefit from thinner, lighter lenses? have interest in a "test drive" of the latest contact lenses? spend time outdoors? have prescription sunwear? prefer not to wear your glasses at times? want info on Laser Vision Correction surgery? have more than 1 pair of current Rx eyewear? have family members in need of eyecare?

Have you tried contacts?*

YesNo

Do you currently wear contact lenses?*

YesNo

Are you satisfied with your current bifocal/progressive lenses?

YesNo

Have you used transition lenses?

YesNo

Patient Medical History

Allergies to medications?*

YesNo

Have you had any previous surgeries?*

YesNo

Do you use cigarettes/tobacco?*

YesNo

Have you ever been diagnosed or treated for the following health problems

NoneAllergiesBlood/LymphCancerDiabetesEars/Noes/ThroatFatigueKidneyNeurologicalRespiratoryArthritisBronchitisCholoesterolDigestiveEndocrineGenitourinaryIntegumentary (Skin)Muscle / BonePsychologicalThyroidUnusual Weight Loss / Gain

Family Medical / Eye History

Is there a family medical history of any of the following:*

NoneBlindnessCataractsCorneal ProblemsGlaucomaHeart DiseaseLazy EyeMacular DegenerationRetinal Problems