Step 1 of 4 25% Name* First Last NicknameDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail* Enter Email Confirm Email EmployerReferred ByCommunication Preference E-mail Text Phone InsuranceVision InsuranceInsurance CompanyID NumberLast 4 digits of SSNPrimary Care DoctorDoctor's LocationPolicy HolderPolicy Holder's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Policy HolderSelfSpouseChildOtherDo you have another Vision Insurance to apply? Yes Insurance CompanyID NumberLast 4 digits of SSNPrimary Care DoctorDoctor's LocationPolicy HolderPolicy Holder's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Policy HolderSelfSpouseChildOtherMedical InsuranceInsurance CompanyID NumberLast 4 digits of SSNPrimary Care DoctorDoctor's LocationPolicy HolderPolicy Holder's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Policy HolderSelfSpouseChildOtherDo you have another Medical Insurance to apply? Yes Insurance CompanyID NumberLast 4 digits of SSNPrimary Care DoctorDoctor's LocationPolicy HolderPolicy Holder's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship to Policy HolderSelfSpouseChildOther Health HistoryReason for the visitEye Comfort Questions Burning/Red Itchy/Watery Dry/Gritty Eye Fatigue Headaches Blurry Vision Medications you are currently takingI have allergies to the following medicationsOther known allergiesSmoking Status*NeverCurrentQuitHave you ever had any eye surgeries?*YesNoWhat eye surgeries have you had?I have been diagnosed with: Diabetes Glaucoma Macular Degeneration Hypertension High Cholesterol Autoimmune Condition Other None Please listI have a family history of: Diabetes Glaucoma Macular Degeneration Retinal Detachment Family History Unknown Other None Please listMy vision is important for these activities Reading Computer Driving Skiing Baseball/Softball Football Golfing Basketball Shooting/Hunting Fishing Digital Gaming None Other visual tasks important to you: Macular Risk AssessmentAMD Risk Factors (check all that apply) Age (over 50) Family history of macular degeneration Smoker (current or prior) High Blood Pressure Caucasian Light Colored Eyes Extended Computer/Phone Use It is recommended that we measure your macular pigment density if you have checked off three or more risk factors. This simple test will help the Doctor determine your risk factor for Macular Degeneration and set up a prevention plan.*Yes I am interested in the testNo, thank youFinal QuestionsDo you wear contact lenses?*YesNoBrand/RxAre you interested in discussing Lasik?*YesNoIs there anything else you want us to know about you or your eyes?Anything else you want us to know about you or your eyes?PhoneThis field is for validation purposes and should be left unchanged.
