COVID-19 Information Have you or anyone in your home experienced a fever in the last 14 days?
No Yes
Have you traveled outside of our area in the last 14 days? If yes, where
No Yes
Patient Information
Personal Information Preferred Language*
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Race*
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Ethnicity*
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Marital Status
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Employment Status
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Communication Preference
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Glasses History
Contact Lens History
Medical History Please list all prescription and over-the-counter medications you take and for what conditions here or upload your file below
Please list all drug allergies you have
Medical Insurance Please bring all insurance cards with you to your appointment.
Vision Insurance Please bring all insurance cards with you to your appointment.
Insurance Photos Please upload a copy of your insurance cards.
ID Please upload a copy of your ID.
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