TODAY'S DATE
  

* NAME
   

STREET ADDRESS
   


TELEPHONE (At least one number is required)
 Example: 555-555-0000

  

* E-MAIL ADDRESS

Please remember to bring all insurance cards as well as a photo ID to your appointment.

INSURANCE TYPE

PLEASE ANSWER THE FOLLOWING QUESTIONS ...

Do you wear contect lenses? Yes | No
Glasses? Yes | No
Are you interested in new glasses? Yes | No

REASON FOR TODAY'S VISIT

DATE OF LAST MEDICAL EXAM
  

PRIMARY CARE DOCTOR


DOCTOR'S PHONE

LIST ALL MEDICATIONS THAT YOU TAKE

LIST ANY ALERGIES TO MEDICATIONS

Have you ever experienced any of the following?
Floaters / Spots | Flashers | Double Vision | Eye Injury | Head Injury

PLEASE LIST ANY EYE SURGERIES WITH DATES

Do you have any of the following?
Diabetes | Thyroid Disease | Hypertension | Other

Females: Are you pregnant? Yes | No | If so, How many months?

Do you use any recreational Drugs? Yes | No

Do you smoke? Yes | No

Does anyone / has anyone in your immediate family had:
Cataracts | Glaucoma | Retinal Detachment
Macular Degeneration | Lazy Eye | Other

* PLEASE LIST ANY ADDITIONAL COMMENTS.

TERMS:
I give Family Eye Care services / Dr. Kaplan permission to bill my insurance listed above. I am aware that I am financially responsible, in full for all services rendered on this date and any other dates of service that are not covered by my insurance plan. By clicking on the "Submit" button you agree the terms listed and that all information in true to the best of your knowledge.