ESTABLISHED Patient Info

Welcome back! We are delighted you are visiting with us again! Please fill this out at least one day before your appointment. If your insurance has CHANGED, please email or text a photo of the card. Our email is info@vistavisioneyes.com and our text number is 318-935-5080.Thank you! Dr Jorgensen and the Vista Vision Staff!

Established Patient History

* Indicates required field

Patients Name *

First

Last

Patients Date of Birth (MM/DD/YYYY) *

Cell Phone Number *

Email *

Current Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

If you have eyeglasses from us, are you seeing great with them? *

Yes No

If you have contact lenses with us, are you seeing great with them? *

Yes No

If you do wear Contact Lenses, how many days per week? *

Please list any NEW health problem diagnosis since we last saw you *

If you have Diabetes, what was your last A1C and when was it taken? *

Are you using any eye drops? *

Yes No

Please type any new vision or eye changes you would like to address to Dr Jorgensen *

Enhanced Digital Eye Scan- Most thorough digital scan of your retina to ensure complete eye health. No drops, easy and quick. $49 fee for this enhanced exam ($45 if you have had it before) *

Yes! I want this done today! I know it is important to do a deeper check on my retina. It is only a nominal fee of $49 (or $45 if you have had this done before here) No - I know this is important but I decline today Maybe - I would like Dr Jorgensen to discuss this with me

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Established Patient History

We Would Love to Have You Visit Soon!

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