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.!