Returning Patient Form "*" indicates required fields Name* Last Name: Given Name: Preferred: Address:* City: Postal Code: Phone Number (cell/home):Date of Birth:* MM slash DD slash YYYY Alternate Number (cell/home):*Any particular concerns for today’s visit?*Date of last medical:*Doctor’s Name:*What is your occupation?*How much screen time do you have each day?*Are you currently taking any medications? If so, please listDo you have any sensitivity or allergies to any medications or substances?*Any changes to family history related to eye disease? If so, please listDo you wear the follow? Please check all that apply* Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses I don’t wear any of these. What do you use most of the time? Please check all that apply* Prescription Glasses Prescription Sunglasses Non-Prescription Sunglasses Contact Lenses I don’t wear any of these. Δ
