Pre-Registration Form

E-mail: webmaster@eyesandcontacts.com

Hours of Operation:
Monday - Friday 9:00 AM to 5:30 PM
We Accept:

601 Market Street
Kirkland, Washington 98083

Phone: (425) 822-8204

Specialties:

Custom Designed Soft & Rigid Contact Lenses & Lasik Surgery Evaluations

Providing High Quality Eye Care For You and Your Family!

PERSONAL INFORMATION

NAME: DATE:

Last First Initial

ADDRESS:

City State Zip Code

PHONE: Home - Work - Cell -

DATE OF BIRTH: / / S.S. #: - -

EMPLOYER: How Long? OCCUPATION:

NAME OF FAMILY PHYSICIAN:

SPOUSAL INFORMATION

NAME: DATE:

Last First Initial

Work Number: -

DATE OF BIRTH: / / S.S. #: - -

EMPLOYER: How Long? OCCUPATION:

DO YOU HAVE VISUAL INSURANCE? YES NO (CIRCLE ONE)

COMPANY NAME:

UNION LOCAL #: S.S.#: - -

WHAT IS THE REASON FOR YOUR VISIT TO OUR OFFICE TODAY?
(List visual complaints, if any.)

HAVE YOU WORN GLASSES OR CONTACTS BEFORE?

MEDICAL INFORMATION

ARE YOU PRESENTLY TAKING ANY MEDICATION?
(Include any over-the-counter medications or birth control pills.)

Who may we thank for referring you here?

PAYMENT, IN FULL, IS REQUIRED
WHEN SERVICES ARE RENDERED!!
ANY PORTION OF THE BILL NOT COVERED BY INSURANCE
IS THE RESPONSIBILITY OF THE PATIENT.

WHO IS RESPONSIBLE FOR THIS BILL? (If you are a minor.)

PAYMENT PLAN: CASH CHECK VISA MASTERCHARGE (CIRCLE ONE)

SIGNATURE: DATE: