Established Patient Information Form
Please complete form and then email to our office (sent on secure server).
Name
*
Prefix
First
*
Last
*
Suffix
Age
Email
Name of policy holder
Vision ID Number
Single Line Text
Policy holder date of birh
MM
/
DD
/
YYYY
We need this information to determine benefits
Last four digits of policy holder's social security
Name of health insurance
Health insurance ID number
If under 18, parents full name
List any allegies
List any medications
Since your last eye exam with Dr. Apted have you had LASIK eye surgery?
Yes
No
Been re-fit into another type of contact lens?
Yes
No
Been diagnosed with hypertension?
Yes
No
Been diagnosed with diabetes?
Yes
No
Do you have a family history of (blood relations only) glaucoma?
Yes
No
Unsure
If yes, who in your family?
Macular degeneration?
Yes
No
Unsure
Diabetes?
yes
No
Unsure
Retinal Detachment?
Yes
No
Unsure
If you have moved since your last exam, please provide us with the new information. Thank you.
Street Address
City
State
Zip code
Phone number
Now please cliick on the "Send" button below. Thank you!
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