New Patient Information Form

New Patient Information Form

New Patient Information Form

New Patient Information Form

Do You Wear : Glasses or Contacts ?
Do you want to try disposable contacts today?
Current Contacts Brand/Power:

Do you or Have you EVER had any of the following. Please Explain Below:

Diabetes

Diabetes Type

Eye Surgery

Irritation

Respiratory Condition

Stye / Chalazion recurring

Headaches

Headaches

Difficulty driving at night?

Want Corrective Surgery?

Retinal Detachment

Redness

Heart Condition

Blindness/Loss Vision

Glaucoma

Injury

Trouble with glare?

Work under fluorescent Lighting?

Burning Eyes

Cataracts

Double Vision

Thyroid

Thyroid Type

Macular Degeneration

Flashes of Light/Floaters

Computer 5+ hours a day?

High Blood Pressure

Lazy Eye

Lazy Eye (R / L)

Seasonal Allergies

Head/Eye Injury

Chronic Infections

Discharge/ Mucus

Need safety eyewear?

Pregnant ?

Nursing?

Do you have an Insurance?

Patient Insurance Information

Vision Insurance

I attest that the information above is correct and I give permission to use this information to file my insurance for coverage of examinations, medical and or routine vision as well as all materials. If the insurance information listed above does not pay/is not valid I Understand that I am responsible for all fees and balances due. I also understand that I will pay them in full before receiving any items and/or services from the Optic Owl CO. and Dr. Bonomolo Fukuzato OD. Eyecare.

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