Welcome to Our Office

Patient Information (According to Record)

Patient Information (Changes Only)

(Please complete in the corresponding field below any information that is either incomplete or incorrect in our records. Thank you.)

Insurance Information 

Current Eye Health

Contact Lens History

Very Important! New Patients Only

Additional information to be completed on back.

The mission of Professional Vision Services is to contribute to a lifetime of healthy vision, providing each patient with the highest quality vision care and consequent quality of life. We will seek continuing education to remain at the forefront of our profession and will offer the latest eye care technology, professional services, and products. The visual needs and wellness of each patient will always be our first priority. Everything we do shall communicate this.

Please, if you have your insurance cards we would like to make a scan for our records.

Lifestyle Questions

Medical History

CURRENT MEDICATIONS (Rx or Over the Counter)

If you have a list of your medications, we can copy.

Date of your last vision analysis?

Have you ever experienced, been diagnosed or treated for any of the following?

Have you ever been diagnosed or treated for the following health problems?

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not Professional Vision Services. 

If your insurance company has not reimbursed our office in full within 60 (or 90) days, you will be billed by us, and your insurance company will then pay you directly. (If by mistake your insurance company sends the payment check to us, we will of course credit your account and if requested can reimburse you by check.)

The information in this confidential case history form is critical to the evaluation of your vision and health.

Patient Information (According to Record)

Patient Information (Changes Only)

(Please complete in the corresponding field below any information that is either incomplete or incorrect in our records. Thank you.)

Insurance Information 

Current Eye Health

Contact Lens History

Very Important! New Patients Only

Additional information to be completed on back.

The mission of Professional Vision Services is to contribute to a lifetime of healthy vision, providing each patient with the highest quality vision care and consequent quality of life. We will seek continuing education to remain at the forefront of our profession and will offer the latest eye care technology, professional services, and products. The visual needs and wellness of each patient will always be our first priority. Everything we do shall communicate this.

Please, if you have your insurance cards we would like to make a scan for our records.

Lifestyle Questions

Medical History

CURRENT MEDICATIONS (Rx or Over the Counter)

If you have a list of your medications, we can copy.

Date of your last vision analysis?

Have you ever experienced, been diagnosed or treated for any of the following?

Have you ever been diagnosed or treated for the following health problems?

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not Professional Vision Services. 

If your insurance company has not reimbursed our office in full within 60 (or 90) days, you will be billed by us, and your insurance company will then pay you directly. (If by mistake your insurance company sends the payment check to us, we will of course credit your account and if requested can reimburse you by check.)

The information in this confidential case history form is critical to the evaluation of your vision and health.