Advanced Eye Care Center Welcome Form

Advanced Eye Care Center Welcome Form

Advanced Eye Care Center Welcome Form

Advanced Eye Care Center Welcome Form

Advanced Eye Care Center Welcome Form

Please fill in the form below.
*Required fields

Date

First Name*

Last Name*

Birth Date

Age

Sex

Address

Street Address

City

State

Zip Code

Cell Phone*

Home Phone

Occupation (or Grade)

Can we text you appointment reminders?

Email*

How did you hear about our office?

Date of your last eye exam?

Do you have insurance?

Do you currently or have you ever had any problems in the following areas?

Constitution

Ear/Nose/Throat

Neuro

Psych

Cardiovascular

Respiratory

Gastro/Intestinal

Genito/Urinary

Musk/Skel

Skin

Diabetes Type

Hem/Lymph

Allergy/Imm

Others

Do you have a primary medical doctor?

Are you taking any medications?

Are you allergic to any medications?

Do you smoke?

Do you drink?

Do you use illegal drugs?

Personal Eye History

Are you planning on purchasing eyeglasses today?

Any past eye surgeries?

Do you wear contact lenses?

Are you interested in wearing contact lenses?


Have you been diagnosed or treated for any of the following?

Diabetic Retinopathy

Macular Degeneration

Eye Turn

Retinal Detachment

Cataracts

Glaucoma

Iritis/Uveitis

Lazy Eye/Injury


Do you experience the following symptoms?

Gritty or sandy sensation

Eye Pain

Fluctuating Vision

Flashes of light

Blurry vision at distance even with glasses

Blurry vision up close even with glasses

Red, itchy, watery eyes or swollen eyelids

Floaters in vision


Consent*

Signature*

Date*

none 10:00 AM - 6:00 PM 10:00 AM - 6:00 PM 10:00 AM - 6:00 PM 10:00 AM - 6:00 PM 10:00 AM - 6:00 PM 9:00 AM - 4:00 PM Closed optometrist https://www.google.com/search?q=advanced+eye+care+vancouver&sxsrf=ALeKk00ZQI7Mt1gm9iqNV429lnvNt4tB_Q%3A1621218271297&ei=39OhYITbEYCEr7wP7t6O-Ac&oq=Advanced+Eye+Care+van&gs_lcp=Cgdnd3Mtd2l6EAEYADILCAAQxwEQrwEQywE6BwgAEEcQsAM6BQgAEMsBOggIABDJAxDLAToGCAAQFhAeUO0_WJtMYJViaAJwAngAgAGWAYgBxASSAQMxLjSYAQCgAQGqAQdnd3Mtd2l6yAEIwAEB&sclient=gws-wiz#lrd=0x5495a4c7c28dac39:0x6f6638da2a62a571,1,,, https://www.yelp.com/writeareview/biz/Rltww-3gOeeBKAbKuTfhPw?return_url=%2Fbiz%2FRltww-3gOeeBKAbKuTfhPw&source=biz_details_war_button https://www.facebook.com/AdvancedEyeCareCenterWA/reviews/?ref=page_internal https://www.google.com/search?q=Battle+Ground+vision+center&sxsrf=ALeKk01N63T4M41CgwV-wEjNGhlNF1Qsyg%3A1621218195774&ei=k9OhYLrfLsmRr7wPjMqe8Ao&oq=Battle+Ground+vision+center&gs_lcp=Cgdnd3Mtd2l6EAMyCwgAEMcBEK8BEMsBMgYIABAWEB4yBggAEBYQHjoHCAAQRxCwAzoICC4QywEQkwI6BQgAEMsBOgcIABAKEMsBOgUILhDLAToHCC4QChDLAToICAAQyQMQywE6BggAEA0QHjoLCAAQyQMQFhAKEB46CAgAEAgQDRAeOggIABANEAUQHlDTMljolAFg0pUBaAFwAngAgAFqiAH3CpIBBDEzLjKYAQCgAQGqAQdnd3Mtd2l6yAEIwAEB&sclient=gws-wiz&ved=0ahUKEwj69KW11M_wAhXJyIsBHQylB64Q4dUDCA4&uact=5#lrd=0x5495b47d63353e9b:0x75344de4b410954,1,,, https://www.yelp.com/writeareview/biz/vHSkwdPJT3c_1zs3pm37kg?return_url=%2Fbiz%2FvHSkwdPJT3c_1zs3pm37kg&source=biz_details_war_button https://www.facebook.com/BattleGroundVisionCenter/reviews/?ref=page_internal https://www.google.com/maps/embed?pb=!1m14!1m8!1m3!1d5582.135845435491!2d-122.502629!3d45.609279!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x5495a4c92eb7d775%3A0x72c7bd3e965e9862!2s16415%20SE%2015th%20St%2C%20Vancouver%2C%20WA%2098683%2C%20USA!5e0!3m2!1sen!2sph!4v1626821935472!5m2!1sen!2sph" width="600" height="450" style="border:0; info@advancedeyecarecenter.org info@battlegroundvisioncenter.com https://www.google.com/maps/embed?pb=!1m14!1m8!1m3!1d5565.003976632178!2d-122.534069!3d45.78117!3m2 !1i1024!2i768!4f13.1!3m3!1m2!1s0x5495b46173059b4d%3A0x3e1b1dae9f8f1a91!2s302%20E%20Main%20St%2C%20Battle%20Ground%2C%20WA%2098604%2C%20USA!5e0!3m2!1sen!2sph!4v1626821974245!5m2!1sen!2sph https://s3.amazonaws.com/static.organiclead.com/Site-b1419620-725b-4f98-9a41-78e0b9c52ecf/GlobalAssets/advance_logo_white.png https://goo.gl/maps/ALksbh8VQfNom9TQ8 https://goo.gl/maps/KYatqmwYvpcMAxZu9 https://s3.amazonaws.com/static.organiclead.com/Site-b1419620-725b-4f98-9a41-78e0b9c52ecf/GlobalAssets/battle_logo.png 302 E. Main Street
Battle Ground, WA 98604 3606875123 https://www.facebook.com/BattleGroundVisionCenter https://www.instagram.com/battlegroundvision/ 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 6:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM Closed Closed