Contact Lens Wearer Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Emergency Contact Name and Relationship

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How long have you been wearing contact lenses?

What type of contact lenses do you currently use?

How many hours per day do you typically wear your contact lenses?

What lens care solution do you use?

Do you experience any discomfort or complications while wearing your lenses?

Do you have any known allergies or medical conditions?

When was your last comprehensive eye exam?

Date

Please provide any additional information or concerns regarding your contact lens use.