First Name:	Last Name:
Birth Date:
Phone Number
Email Address:
How did you hear about my practice? A friend Internet Practice Staff Member Advertisement Yellow Pages Other
How did you find my website? Search Engine Advertisement A friend Don't remember
If a doctor suggested you see us, please provide the following information:
Name Phone: Address:
Why are you interested in vision correction?
Medical and Eye History:
With eyeglasses or contacts on, how much nighttime glare or halos do you have? None Minimal Mild Moderate Severe
List all eye surgeries, injuries, or diseases you have had:
List all medical problems you have:
List all eyedrops you use, which eye, and how often you use them:
If female, are you or might you be pregnant?	yes no