ESTABLISHED Patient Info

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About
Contact us
NEW Patient Info
ESTABLISHED Patient Info
Contact Lenses
Frame/Lens Replacement
Wellness Exam
Schedule an Exam
Eyeglass Lenses

Home
About
Contact us
NEW Patient Info
ESTABLISHED Patient Info
Contact Lenses
Frame/Lens Replacement
Wellness Exam
Schedule an Exam
Eyeglass Lenses

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) *

12/15/1960 for example

Cell Phone Number *

Email *

Current Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

NO PO Box please

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? *

Answer from 1 to 7

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

Health issues like Diabetics, High blood pressure, etc.... If none, write NONE

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

For more information, please visit the tab titled Wellness exam

I agree to Dr Michael W Jorgensen OD LLC and Vista Vision LLC privacy policy and payment policy

To view this policy, click the black box below titled "Privacy Policy"

Submit

We Would Love to Have You Visit Soon!

Hours

Tu-Fri 8:30 - 5:30 pm
Saturday 9:00 - 2:00 pm

Telephone

318-935-5080

Email

info@vistavisioneyes.com