Patient Registration Form

Please check any conditions you are currently suffering from: Required

Please check all that apply: Required

Eyeglasses / Contact lens history: Required

I wear eyeglasses for driving /distance

I wear eyeglasses for reading

I wear contact lenses

Please check anyone in your immediate family with the following conditions: Required

Do you currently suffer from any of the following conditions: Required

Have you been exposed or infected with: Required

Eye History