Patient Information - Prism Optical Chicago

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Patient Information

Patient Name *

First

Last

Email *

Contact Phone Number *

Best Contact Method *

Address

City

Zip

Date of Birth *

Reason for Visit? *

Do you have Vision Insruance? If so which one: EyeMed, Davis Vision, VSP, Aetna, Spectera, Other *

Sign me up for the free Prism Vision Plan (Yes or No) *

When was your last eye exam?

Do you smoke cigarettes?

Have you ever had surgery on your eyes?

If yes, please explain below:

Do any family members suffer from a serious eye disease??

If yes, please explain below:

Do you suffer from any of the following?

Are you pregnant?

Have you ever had your eyes dilated before?

If yes, what year?

Are you taking any eye drops (prescription or over the counter)? Please List.

Are you taking any other medications (prescription or over the counter)? Please List.

I had read the COVID-19 statement letters found on the navigation menu *

I had read the HIPAA statement letter found at the top of this page *

I understand Prism Optical is not responsible for any order I don’t pick up within 90 days. *

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