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