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Name:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Email Address:

Date of Birth:

Social Security #:

Insurance Company/Group/ID#:

Emergency Contact Person:

Relationship:

Emergency Contact Telephone:


I would like to be contacted for an appointment.

Yes

No

( Not at this time. I will call your office at my convenience.)


I would like my appointment confirmed the day prior to my visit by

Telephone

E-mail


I request a free LASIK screening and have completed the registration above.

Yes

(we will call you to set up a convenient time)

No

Not at this time, but add me to your mailing list.


**Please bring your insurance card with you to your appointment if you would like for us to file your insurance claim.