Patient Forms

Welcome to Vision World. Have a Clear Day!

Patient Information Form

Address
Address
City
State/Province
Zip/Postal
How did you hear about us? (select one)
Do you have any difficulties seeing? (select all that apply)
Are you interested in Digital Eyeglass Technology for better vision under stressful conditions?
Are your eyes Dry, Itchy, Gritty, Red
Do you have difficulty seeing at night?
Are you interested in contact lenses?
Are you interested in Laser Vision Correction or Lens Replacement Refractive Surgery
Do you have Hypertension or Diabetes?
Do you have any allergies?
Are you taking any medications or supplements?
Are you familiar with Anti-Oxidants and their importance for eye health of all ages?
I authorize release of any medical information necessary to process any insurance claims & I authorize payment of medical benefits directly to the physician or supplier of services for myself and or dependents. I understand I am responsible for any deductlbles, co-Insurance, or amounts for services not covered by insurance carrier.