Thank you for choosing Vision First for your eye care needs. Please complete
this form as accurately and thoroughly as possible.
Please bring your current glasses and contact lens boxes or prescription
with you to your appointment.
I authorize the release of medical information necessary to provide the
most beneficial / complete visual examination. I understand that I am financially
responsible for all charges whether or not paid for by insurance.
I have been given and opportunity to read and/or receive a copy of the
Notice of Privacy Practice Acklowledgement. A copy of this acknowledgement
can be found on our website.
CONTACT LENS PATIENT: Your success with contact lens depends upon follow-up
care. We would like to see you after one week of wearing your new contacts.
There is no charge for this follow up visit. It is your responsibility
to schedule and keep this appointment. Further, contact lenses are medical
devices. They can cause serious eye problems without proper care and routine
follow-up. Therefore, OUR OFFICE CANNOT RELEASE YOUR CONTACT LENS PRESCRIPTION
WITHOUT FINALIZING YOUR CONTACT LENS EXAM WHICH INCLUDES THE FOLLOW-UP
VISITS AT THE DOCTOR'S DESCRETION.
(By typing your name here, this acts as your signature in an electronic
Thank you for your patience in completing your patient information form
and we look forward to meeting you soon!