New Patient Form

New Patient Paperwork
*Indicates Required Fields

Patient Information
Lifestyle Questions

Do you...(check all that apply)
Have you tried contacts?*
Do you currently wear contact lenses?*
Are you satisfied with your current bifocal/progressive lenses?
Have you used transition lenses?
Patient Medical History
Allergies to medications?*
Have you had any previous surgeries?*
Do you use cigarettes/tobacco?*

Have you ever been diagnosed or treated for the following health problems
Family Medical / Eye History

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

Additional Forms

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