Established Patient Information Form
Please complete form and then email to our office (sent on secure server).
Name of policy holder
Vision ID Number
Single Line Text
Policy holder date of birh
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?
Been re-fit into another type of contact lens?
Been diagnosed with hypertension?
Been diagnosed with diabetes?
Do you have a family history of (blood relations only) glaucoma?
If yes, who in your family?
If you have moved since your last exam, please provide us with the new information. Thank you.
Now please cliick on the "Send" button below. Thank you!
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