Northern Lights Eye Care

Name*

First Last

Date of Birth*

MM

DD

YYYY

Driver's License Number

Social Security Number

Email*

Marital Status*

Address*

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

Home Phone

Cell Phone

Business Phone

Name of Parent or Spouse*

First Last

Have we examined other members of your family?*

Yes
No

Occupation

Employer

Primary Medical/Vision Insurance Company*

Member Name*

First Last

Member DOB*

Member Number*

Do you have Secondary Insurance?*

Yes
No

Secondary Insurance Company

Member Name

First Last

Member Number

Name of Family Physician*

First Last

How Did You Find Out About Our Office*

What Is Your General Health Status?*

List All Medications You Are Taking*

Pharmacy Name*

Pharmacy Phone Number*

Medication Allergies*

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years*

Are You Pregnant?*

Yes
No

Name of Last Eye Doctor*

First Last

Date Of Last Eye Exam*

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No