Patient Information         Date:___________

      

 

Last Name:___________________________First Name:_______________________________MI:_____     

 

DOB__­________/___________/__________ Age:_________                              Chart#:_______________

 

Home address:___________________________________________________________________________

 

City:_____________________________________________State:__________Zip:____________________

 

Home Phone:________________________________e-mail address:_______________________________

 

Employer:__________________________________  Occupation:___________________________________

                                                                                       visual requirements_____________________________

Employer’s Address:__________________________ City:________________State:_____Zip:____________

 

Work Phone:________________________________Can we contact you at work if necessary?  Yes / No

 

Emergency Contact:  Name______________________________Phone Number:______________________

 

Optometrist:____________________________________________________________________________

 

­       How did you hear about Optivision?  Newspaper  /  Radio  /  TV Infomercial  / TV commercial / Internet  /  Friend  /  Other

 

­       Please specify radio station, which paper or name of friend________________________________________

 

­       What has stopped you from having LASIK in the past?___________________________________________

 

­       Hobbies and visual needs required____________________________________________________________

 

­       When would you like to have surgery?_______________________________________________________

Text Box: FOR OFFICE USE                                                                **   For office use_______________