ARE YOU INTERESTED IN WEARING CONTACT LENSES? Yes Maybe

No

ARE YOU INTERESTED IN HAVING LASER VISION CORRECTION? Yes Maybe No HOW MANY HOURS PER DAY DO YOU SPEND ON A COMPUTER? 0 - 2 - 4 - 6 - 8 - 10 - 12 - more DO YOU EXPERIENCE ANY EYE STRAIN FROM YOUR COMPUTER? Yes No WHAT TYPES OF HOBBIES OR ACTIVmES ARE YOU INVOLVED IN?

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LIST ANY OTHER VISUAL NEEDS

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DO YOU WEAR SUNGLASSES? Prescription

Non-Prescription

NAME OF VISION INSURANCE:

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NAME OF INSURED (PRIMARY): DO YOU HAVE A FLEXIBLE SPENDING ACCOUNT (HSA)?

DOB (PRIMARY): Yes

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No

NAME OF MEDICAL INSURANCE:

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PPO/HMO

NAME OF INSURED (PRIMARY):,

DOB (PRIMARY):,

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MEDICAL INSURANCE ID #:

GROUP #:

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NOTE: PAYMENT IS EXPECTEDAT THE TIME SERVICES ARE RENDERED. WE WILL BE HAPPY TO

ASSIST YOU WITH BILLING YOUR INSURANCE COMPANY. I AUTHORIZE TREATMENT FOR THE PATIENT NAMED ABOVE AND ACCEPT RESPONSIBILITY FOR ALL CHARGES INCURRED AT THIS OFFICE.

SIGNATURE ON FILE: I AUTHORIZE THE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANIES. I AUTHORIZE MY DOCTOR TO ACT AS MY AGENT IN HELPING ME OBTAIN PAYMENT FROM MY INSURANCE COMPANIES. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.

SIGNATURE:

DATE:

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