• Welcome to Advanced Optical and thank you for choosing us for your eye health and vision care needs. In order to prepare for your evaluation and for us to provide you with the best care for your individual needs, please review and complete the attached forms.

  • GENERAL INFORMATION

  • Sex*
  • Marital Status*
  •  -
  •  -
  •  -

  • Emergency Contact

  •  -
  • Date of Last Eye Exam*
     - -
    2 digit month, 2 digit day, 4 digit year
  • How did you find about our office?*

  • Acknowledgement of Receipt of Notice of Privacy Practices

    I understand that I have certain rights to privacy regarding disclosure of my health information. I understand that this information may be used to direct treatment, payment, or health care operations. Unless I decline, relevant information may be shared with family involved in my eye care. I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. I understand that I may request, in writing, to restrict how my information is shared. By signing below, I acknowledge the above and that I have reviewed or been given the opportunity to review Advanced Optical’s Notice of Privacy Practices (available on our website at www.advancedopticaleyes.com), which further details the uses and disclosures of my health information. 

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Financial Agreement

    I understand that I am financially responsible for all charges and it is my responsibility to pay balances not paid by insurance. I understand that most insurances do not pay for refractions (to obtain an eyeglass prescription). If I have a refraction, I am responsible for the refraction fee of $75. Payment is due at the time services are rendered.

    We, at Advanced Optical, sincerely appreciate your business and we strive to offer you the very best in products and services. Making high quality eyewear takes time and expertise. These are custom items made specifically for you in order to meet your needs. Hence these items cannot be reused or returned to the manufacturer. Therefore, there are no returns or refunds on any prescription eyewear. Rest assured we will make every effort to correct any issue you may have and work with manufacturers directly on your behalf. It is of the utmost importance to us that you are seeing well and you love the way you look and feel with your new glasses and/or contacts.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • MEDICAL HISTORY QUESTIONNAIRE

  • Please check all that apply*
  • Do you currently have a problem with any of these systems? Please check all that apply: *
  • Any allergic reactions to medications or other substances (latex, etc.)?*

  • General Physician

  •  -
  • Do you smoke?*
  • Do you drink alcohol?*
  • Do you take medications?*
  • Do you use other substances?*
  • Do you have family history of any of the following?*

  • VISION & LIFESTYLE QUESTIONNAIRE

  • Please complete this questionnaire so we can better understand your daily vision needs.

  • How many hours a day do you spend per activity?

  • Do you drive?*
  • Do your eyes feel tired or strained at the end of the work day? *
  • Do you experience sensitivity to light?*
  • Does glare bother you?*
  • Do you regularly participate in outdoor exercise?*
  • Do you regularly participate in any contact sports?*
  • Do you wear sunglasses with UV protection? *
  • Does driving at night bother you?*
  • Eyewear Needs*
  • Occupational Needs*
  • What is important to you?*
  • Should be Empty: