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First Name

Last Name

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email

Occupation

Employer

Employer Phone

Employer Address

Employer City

Employer State

Employer Zip Code

Contact in case of emergency

Relationship

Emergency Contact Phone

Responsible party for minor

Relationship

Responsible Party Phone

Medicaid Number

Medicare Number

Insurance Company

Do you have Vision Coverage?
Yes
No

Customer Service Phone

Group #

Member ID

Eye Health Questions
Since your last eye exam, with your best vision correction on, have you suffered from

near vision blur
distance vision blur
middle distance vision blur
double vision
headaches
seeing spots/lines
seeing flashes
seeing halos
dry eyes
watery eyes
pain in/around eyes
red eyes
change in focus from near to distance
change in focus from distance to near
outdoor glare
indoor glare
eye strain

Patient information

Schedule information