P 912.466.9500
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Please fill out answer these 3 questions and we’ll call you to set up an appointment. You can also reach us during the day at: (912)466-9500.
First and Last Name:
Email Address:
Confirm Email:
Phone Number:
Reason for your visit:
Pre-registration
Please take a moment to complete the following survey below, or print it and bring it with you to your appointment. The completed survey will expedite your visit with us, and the information entered is protected by
our HIPPA policy
.
Patient Name:
Email Address:
Confirm Email:
Date of Birth:
SSN:
Occupation:
Marital Status:
Address:
Telephone number(s):
Primary Insurance Carrier and number
(if available)
Secondary Insurance Carrier
Vision Insurance Carrier
Please check any that apply to you.
Cataracts
Glaucoma
Macular degeneration
Diabetes
Hypertension
High cholesterol
Sleep Apnea
Heart Disease
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Rheumatoid Arthritis
Thyroid Disease
Cancer (enter type below)
Cancer type (if any):
Other illnesses (if any):
Allergies:
Please list any surgeries you have had
Current Medications
(include eyedrops and vitamins)
Preferred Pharmacy
How did you hear about our office/doctors?
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Other (please elaborate below)
Other Referral
Would you like to be tested for new glasses
and/or contact lenses during your appointment?
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No
Additional Information
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