Contact Us
First Name:
Last Name:
Birth Date:
Phone Number
Email Address:
How did you hear about my practice?
A friend
Internet
Practice Staff Member
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Yellow Pages
Other
How did you find my website?
Search Engine
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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
Copyright © 2006 Southland Eyecare Associates.