NEW PATIENT FORM

2680 Coolidge Hwy

Berkley, MI 48072

PHONE: (248)-629-6410     Email: andy@berkleyeyewear.com

Please complete ALL requested information in this form. Incomplete applications will be denied.

 

GENERAL INFORMATION

 

INSURANCE INFORMATION

 

EYE HISTORY

 

MEDICAL HISTORY

Have you or a family member experienced, or been treated for, any of the following? Tick all that apply.


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Blurry VisionBurningDischargeDouble VisionDrynessExcess Tearing/WateringEye InfectionEye Pain or SorenessFloaters or SpotsHalosHeadachesItchingLight FlashesLight SensitivityRednessSandy or Gritty Feeling

 



 

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Thank you for choosing Berkley Eyewear & Local Sunglass Co.!