|
|
|
|
This Patient Information form is provided for your convenience. Please print the form, complete it, and bring it with you to the clinic. PATIENT INFORMATION Date ___________________ Name _____________________________________ Date of Birth __________ Address______________________City _____________ State ___ Zip_______ Home Phone ___________________ Work Phone _____________________ E-Mail Address ________________________ Age____ Sex ____ Occupation _________________________ Married/Single ________________ Hobbies/Sports ___________________________________________________ Medications ______________________________________________________ ________________________________________________________________ Allergies _________________________________________________________ ________________________________________________________________ Have you ever worn glasses? _____ Contact Lenses? ____ Now wearing? ____ How did you hear about our office? ____________________________________ Children Only/Name of Parent or Guardian ______________________________ Payment is required at the time services are rendered. Please do not ask us to extend credit or bill you. Preferred Method of Payment: ¨ Cash ¨ Check ¨ VISA ¨ Mastercard ¨ DiscoverPrimary Reason for Your Visit Today __________________________________ ¨ I choose to have my eyes dilated for a complete exam and understand my vision may be blurred or light sensitive for 6 hours.¨ I choose not to have my eyes dilated and understand that only a portion of the retina will be examined. ¨ I would like to have the visual field analyzer test today.SIGNATURE ______________________________________________ |