Bauer Optical Eye Care

Welcome Form

Please fill out and submit this form to get started. Or just stop by!

Patient Information:
Name *
Name
Very Important! New Patients Only:
Insurance Information
Do you participate in flex spending account?
How will you settle your account?
Lifestyle Questions
Do you.... (Check all that apply)
Have you ever experiences, been diagnosed, or treated for any of the following ocular conditions?
Patient Medical History
Allergies to any medications?
Have you had any surgeries?
Do you use cigarettes/tobacco, alcohol, or other substances?
Have you ever been diagnosed or treated for the following health problems?
Patient Eye History
Have you ever tried contact lenses?
Do you currently wear contact lenses?
Are you satisfied with the vision and comfort of your contact lenses?
Would you prefer clear contact lenses or colored contact lenses?
If you wear bifocals, do the lines or head tilting bother you?
Family Medical/Eye History
Is there a family medical history of any of the following (check all that apply)
DISCLAIMER AND ELECTRONIC SIGNATURE
I HAVE READ AND UNDERSTAND THE CONSENT FORM AND CONSENT TO THE USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT, AND HEALTH CARE