Spectacular Eye Care

Name (Fields with an asterisk are required.)*

First Last

Birthdate*

Driver's License Number

Last 4 Digits of 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?

Insurance Company*

If No Insurance Company, type "NA."

Is Insurance Subscriber Same as Patient?

Member Name*

First Last

Member DOB*

Member Number*

If No Insurance Company, type "NA."

How Did You Find Out About Our Office

List All Medications You Are Taking*

Medication Allergies*

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

Are You Pregnant?*

Name of Last Eye Doctor*

First Last

Date Of Last Eye Exam

Do You Wear Eyeglasses?*

Do You Wear Contact Lenses*

Current Eyedrops

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries

Do You Use Tobacco Products?

Do You Drink Alcohol?

Patient Eye Health*