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Patient Forms

Eye To Eyecare strives to make your visit as efficient as possible. Our patient forms can be downloaded by clicking on an icon below. Please fill out the forms and bring with you on your visit.


If you have any questions about this form, please contact us and we will respond to your inquiry. Thanks for choosing Eye To Eyecare for your eyecare needs!

Patient Registration Forms

EYE TO EYECARE

Registration Form

PATIENT INFORMATION

TODAY's DATE:





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Check appropriate box*

How Did You Hear About Us?

VISION AND MEDICAL INSURANCE INFORMATION

Do you have Vision Insurance?*
Do you have Medical Insurance?*

OCULAR HEALTH

What do you primarily use to correct your Vision?*
Do you wear glasses?*
Do you wear contacts?*
Do you take eye drops?*
Would you like to try contacts?*
Would you like laser vision correction?*
If yes, for

Please check any symptoms you may be experiencing*:






















OCULAR AND MEDICAL HISTORY


Please check any condition that applies to you*:



















FAMILY OCULAR AND MEDICAL HISTORY

MEDICATIONS AND ALLERGIES



Are you allergic to any medications?*
Do you have general / seasonal allergies?*

Please sign below to indicate that all the information provided above is correct.*



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