Patient Paperwork

To make your exam smooth and simple, we have prepared some pre-exam questions. 

Please fill out ALL sections to the best of your knowledge.  You may leave comments/questions at the end.  Any sections left unfinished will need to be completed at the day of your exam and may increase the length of the exam time.

If you have any questions/concerns or run into a bug we are here to help!  Call us or email us anytime. 

 

The following form will ask some questions about your medical history, previous prescriptions, and how you adapted to the RX.  Here are some sample prescriptions below to help you better understand what will be done.   

Example Glasses RX

Example Glasses RX

Example Contact Lens RX

Example Contact Lens RX

Please complete the form below

Name *
Name
Phone *
Phone
We may need to contact you for additional questions/clarification.
DOB *
DOB
Glasses History
Previous RX - RIGHT EYE - OD
May be Labeled as Sphere, SPH, or S.
May be labeled as CYL
Ranges from 0 to 180 degrees
Previous RX - LEFT EYE - OS
May be Labeled as Sphere, SPH, or S.
May be labeled as CYL
Ranges from 0 to 180
Additional power used for patients who wear progressives lenses or bifocals.
Contact Lens RX
Additonal Medical Info
Do you have any of the following? *
Please check all that apply!
Do you smoke? *
Do you exercise regularly? *
Do you drink Alcohol? *
Do you use recreational drugs? *
Pupil Dilation *
Depending on the findings of your exam, the doctor may wish to use eye drops to dilate your eyes. Common side effects of the drops used in the dilating process are increased glare and reduction in near focusing ability. Distance vision is usually not significantly affected. The process is painless and lasts anywhere from 5-7 hours. If you have questions please ask the doctor or staff.
Contact Lens Evaluation Fees:
Prices are IN ADDITION to the routine glasses exam fee of $99. These services include trial lenses and 2 follow up visits. The evaluation level depends on the final diagnosis and procedures used: Spherical Evaluation (Single Vision): $79.00 Toric Evaluation (Astigmatism): $99.00 Multifocal/Mono Vision Evaluation: $119.00 Specialty/RGP Evaluation: $199.00