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 your last prescription with us, are you seeing good with them? *

Yes No

If you have contact lenses from your last prescription with us, are you seeing good 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 *

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

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Established Patient History

We Would Love to Have You Visit Soon!

Hours

Telephone

Email