The Eye Works

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Home)*

Phone (Work)

Phone (Cell)

Email Address

Date of Birth*

What is your occupation?

Parent / Guardian Name

Marital Status*

Single
Married
Divorced
Widowed

What is the best way to contact you?*

If this is your 1st time here, why did you choose us?*

Major reason for today's visit? (Check all that apply)*

Glasses
Contacts
Laser Correction Information
Eye Health
General Wellness
Other (please explain below)

If you marked "other" above, please explain:

Last Vision Exam & Location*

Currently Wear Contact Lenses?*

Yes
No

If Yes, any issues?

Interested in the newest in contacts?*

Yes
No

Number of hours per day on computer or electronic devices?*

Number of hours per day spent outdoors?*

Do You Have Prescription Sunglasses?*

Yes
No

Do You Drive at Night?*

Yes
No

If Yes, any visual problems?

Interested in Lasik Correction?*

Yes
No

Do you experience, or have you had any of the following? (WITH CURRENT CORRECTION) (Check all that apply)

Personal Medical History (Check all that apply)*

Family History

Diabetes
Glaucoma
Macular Degeneration
High Blood Pressure
Blindness
Stroke

Please write which family member had which disease from the previous question in the space provided below.

List all current medications:*

Last Medical Exam

Physician's Name

Additional Comments:

CANCELLATION OF AN APPOINTMENT: To be respectful of the needs of other patients, please be courteous and call promptly if you are unable to attend your appointment. This time will be reallocated to someone who is in need of our services which includes annual eye exams, comprehensive eye exams and often, urgent care eye exams. This is how we can best serve the needs of our patients. If it is necessary to cancel your scheduled appointment, we require that you call 24 business hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.

HOW TO CANCEL YOUR APPOINTMENT: To cancel appointments, please call 707 254 2020. If for whatever reason you do not reach us, you may leave a detailed message on the voice mail. Late cancellations will be considered a “no show”. A “no show” is someone who missed an appointment without cancelling it 24 hours in advance of your scheduled appointment. No-shows inconvenience those individuals who need access to our care and services in a timely manner. A failure to be present at the time of a scheduled appointment will be recorded in your chart as a “no show”. If there is a second no show, you will have to pay a $50 fee for your missed appointment before scheduling any further appointments.

Date

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The Eye Works Optometry