Thank you for choosing Vision First for your eye care needs. Please complete this form as accurately and thoroughly as possible.

Patient Information


Responsible Party

Vision Insurance Information

Medical Insurance Information


CONFIDENTIAL HEALTH HISTORY

Eye Surgery / Eye Injury

Patient Eye History

Patient Health History

Please bring your current glasses and contact lens boxes or prescription with you to your appointment.

Family Health History

Insurance Authorization, Release and HIPAA

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 version)

Thank you for your patience in completing your patient information form and we look forward to meeting you soon!