Patient Intake Form

Lifetime Eyecare

Please correct the errors described below.

Welcome to Our Office!
Please Complete the Following Information.

Patient Information

If Patient is Under 18 Years or a Student

Medical Information

Vision Insurance Coverage

Medical Insurance Company

About Your Eye Examination

Several procedures are required to examine the health of your eyes and to determine treatment and/or the prescription for your eyewear. The comprehensive examination generally requires the instillation of eye drops to dilate the pupil of the eye. Dilating drops allow the doctor to examine the structures inside of the eye. These drops may result in light sensitivity, hazy vision, and difficulty focusing at near, for a duration of four (4) to eight (8) hours. Please exercise caution while driving, operating equipment, or reading during the duration of these effects.

the use of DILATING DROPS.

Do You Currently

Are You Interested In?

Have You Had?

Social History?

Females?

Other Disorders / Diseases?

Medication

Health History: Do you or any blood relatives have any health conditions? (Mother, Father, Sibling-sister/brother, Grandparent)

Otherwise:

Allergies

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