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Patient Information Form

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1. Patient information

Please fill out the following personal information

Preferred Method of contact (Tell us the best way to reach you) * Email phone Text

Family Doctor Yes No

Do you have insurance? Yes No I am unaware of my insurance information

Do you have dependant coverage?
Yes No

2. Personal Medical History


4. Purpose of your visit


5. Corrective lens information

Your answers to these questions will guide us in recommending the best products to meet your eyewear needs.


a) Do you wear the following?

Please check all that apply. Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses I don’t wear any of these.

b) What do you use most of the time?

Please check all that apply. Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses I don’t wear any of these.