In efforts to serve you most efficiently, please complete the information below and submit the form online, or if you prefer, print it out and bring it with you when you come into our office.  If you have any questions about any of the questions, simply leave blank questions you don't know the answer to...we'll help take care of that when you arrive :-)

Name (first,last)	*
Changes in Address information?		Yes No
changes in personal information (address, phone numbers,emails)		no changes
Changes in Medications or Health History
Can we improve the vision or comfort of your current eyewear?
Can we make your contact lens wearing experience any better?
Changes in Vision or Eye Health Experience?		Burning Tearing Itching Nausea Eye Strain Spots floating in Vision Soreness around eyes Headaches Redness Double Vision Flashes of Light Glare or reflection at night time Dryness Reading problems Other
Do you...
Do You...		...work at a computer for long periods? ...have more than one pair of glasses? ...want more information on thinner, lighter lenses? ...want infomration on visual fatigue relieving lenses? ...wear bifocals? (if yes, are you bothered by head tilting, restricted areas of clear vision?) ...like to change your look with different styles of eyewear? ...have prescription sunglasses? ...have difficulty with your bifocals? ...have any interest contacts lenses? ...experience times you would rather not wear your glasses? ...have any interest in LASER refractive surgery for nearsightedness, astigmatism or farsightedness? ...have problems with glare or reflection, particularly when driving at night? ...participate in medical flexible spending account?
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