Skip to main content

COVID-19 Update: What to Expect in Our Office

Our Commitment to Health and Safety. Read more about our safety protocols.

contact-on-eye Custom Contacts/Scleral eye-low-vision2 Myopia Control eye-inverse Dry Eyes

Call Us! 704-271-5544

BOOK ONLINE
704-271-5544
APPLY NOW
Open Menu
Close Menu
various_colorful_sunglasses_row_1280x480
Home » Patient Registration Form

Patient Registration Form

  • WELCOME TO OUR OFFICE

    Please help us provide you the best possible care by providing the following information.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • (If child)
  • (If child)

  • MEDICAL HISTORY

  • YesNo
    Allergies
    Arthritis
    Asthma
    Cancer
    Diabetes
    Eye Injury
    Eye Disease
    Heart Disease
    High Blood
    Lazy Eye
    Eye Surgery
    Cataracts
    Lung Condition
    Glaucoma
    Thyroid
    Other

  • CURRENT MEDICATIONS

  • FAMILY MEDICAL HISTORY

  • Do You...

  • (a nonsurgical way to get rid of contacts and glasses)
  • Hrs./week

  • Do You Experience...

  • How did you first hear about our office?

Adjust Text Size Normal Large Extra Large