Existing Patient Forms

Existing Patient Forms

Our Office Policy
Is this eye exam for someone under 18?*

YesNo
Patient Name/Guardian Name*

First NameLast Name
Patient Birthday (MM/DD/YEAR)
ex: 01/11/2011
Children Name 1
First and Last Name
Children 1 Birthday (MM/DD/YEAR)
ex: 01/11/2011
Children Name 2
First and Last Name
Children 2 Birthday (MM/DD/YEAR)
ex: 01/11/2011
Children Name 3
First and Last Name
Children 3 Birthday (MM/DD/YEAR)
ex: 01/11/2011
Children Name 4
First and Last Name
Children 4 Birthday (MM/DD/YEAR)
ex: 01/11/2011
Do you have a change in contact information? (e-mail, phone number or address)*

YesNo
Email
example@example.com
Phone Number
Ex: 909-627-1111
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I understand that a copy of Bright Vision Optometry's office policy and privacy policy (HIPAA) is posted for my knowledge and information and that a copy will be made available to me should I request one.

Copy of our office policy
Copy of our privacy policy (HIPAA)

Any requests for amendments need to be sumbitted in writing.

I give Bright Vision Optometry permission to contact me via direct e-mail, phone and/or text messages.

I give Bright Vision Optometry consent to e-mail me copies of my glasses and/or contact lens prescription.
SIGNATURE
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