Patient Information
All answers given are sent to a secure spreadsheet.
Title
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Social Security Number
Your answer
Parent's name if patient is minor
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
We will notify you of upcoming appointments and when your product(s) arrive via text!
Preferred Phone Number *
Your answer
Alternate Phone Number
Your answer
Email Address
We notify our patients of upcoming appointment and when product arrives via email. Please list an email address that is checked frequently.
Your answer
Occupation
Your answer
Employer
Your answer
Student Status
How did you hear about us? *
Required
When was your last eye exam? (An estimate is acceptable.)
MM
/
DD
/
YYYY
Where was your last eye exam?
Your answer
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