Patient Visual Form - Brooks Eyecare

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Brooks Eyecare Mission Statement

Our Mission is to be the premier facility in Kentucky; delivering the highest quality care using the latest in technology and treatment protocols; providing that care with a friendly, knowledgeable, and caring staff.

Patient Visual Information Form

Date: Friday July 25, 2008
Patient Name:
Street Address:
City: , State: Zip:
Patient's Age: Patient's Birthday:
Email Address:
Home Phone:
Alternate Phone:
Check One: Single Married Widow Seperated Divorced
Occupation:
Employer: (If student, please include grade, school and teacher)


What is the purpose of this appointment ? Routine Visual Exam Visual Discomfort Other If you chose 'Other', please explain below:
Are you wearing any visual prescription at this time ? (Check One) Yes No If YES, how old is the prescription ? years
How long has it been since your last visual examination ? years By whom ?
Have you ever been examined by the Optometrists at this office before ? Yes No
Who referred you to the Optometrists at this office ? Referrer's Name: Street Address: City: , State: Zip:
Who will be responsible for the financial aspect of this case ? Person's Name: Street Address: City: , State: Zip: Place of Employment: Employer's Address:
How will the financial aspect of this case be handled ? (check one) Check Cash Credit Card Other