NEW Patient Info - vistavisioneyes.com

vistavisioneyes.com

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NEW Patient Info
ESTABLISHED Patient Info
Frame/Lens Replacement
Wellness Exam
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Dry Eye Spa!

Home
About
Contact us
NEW Patient Info
ESTABLISHED Patient Info
Frame/Lens Replacement
Wellness Exam
Schedule an Exam
Dry eye solutions!
Dry Eye Spa!

Welcome to Vista Vision! Thank you for choosing us and we look forward to solving all your eye care needs! Please fill in this form before you arrive for your visit. If possible, please EMAIL OR TEXT a photo of your Photo ID and Insurance card. Our email is [email protected] and our text number is 318-935-5080. Thank you

New Patient History

* Indicates required field

Patients Name *

First

Last

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

12/15/1960 for example

Email *

Current Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

NO PO box please

Cell Phone Number *

When was your last eye exam? *

1 year ago 2 years ago 3 or more years Never

Do you currently wear eyeglasses? *

Yes No

Do you currently wear Contact Lenses? *

Yes No

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

Answer from 1 to 7

Do you experience any of the following symptoms? (check all that apply) *

Gritty, Sandy feeling eyes Excessive watery eyes Burning/stinging eyes Red eyes None of these

Do you have Diabetes? *

Yes No

Do you have High Blood Pressure? *

Yes No

Do you, or have you ever had, a Lazy/Weaker Eye? *

Yes No

Have you ever had a Retina Detachment or any Retina Surgery? *

Yes No

Have you ever had a Cornea Infection? *

Yes No

Have you ever been diagnosed with Glaucoma? *

Yes No I am a Glaucoma Suspect

Have you ever been diagnosed with Macular Degeneration? *

Yes No

Have you ever been diagnosed with Dry Eye Disease? *

Yes No

Anyone in your genetic blood line have Glaucoma? *

Yes No Unsure

Anyone in your genetic blood line have Macular Degeneration? *

Yes No Unsure

Are you using any eye drops? *

Yes No

consistent or chronic use. If you use one drop every month, select no

Are you taking any Medication (s)? *

Yes No

If you take Medication (s), please list *

If you have a printed list, you can just email it or bring and show to our receptionist

Do you have any allergies to any medications? *

Yes No

If you have any medicine allergies, what medicine are you allergic to? *

Please write anything else you are concerned about so Dr Jorgensen is prepared *

Privacy Policy & Payment Policy *

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

To view this policy, click the "Privacy Policy" button below

Submit

Privacy Policy & Payment Policy

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

[email protected]

Home
About
Contact us
NEW Patient Info
ESTABLISHED Patient Info
Frame/Lens Replacement
Wellness Exam
Schedule an Exam
Dry eye solutions!
Dry Eye Spa!