Plaza Lane Optometry

Welcome Form

Name & Birthdate

Legal Name
 

Birthdate
 

How would you like to be addressed?
 

Adress & Phone Numbers

Address
 

City  State  Zip 

Work Phone
 

Cell Phone
 

Home Phone
 

Additional Information

Email
 

SSN
 

Occupation
 

Employer
 

Account Responsibility

Spouse/Parent (If Minor)
 

Person Responsible for Accont
 

Account Responsible SSN
 

Address
 

City  State  Zip 

Miscellaneous Information

Whom may we thank for referring you to us?
 

In case of emergency, call
 

Phone Number 

List any special interests or hobbies

Would you like information on:

refractive surgery (LASIK)?
 Yes  No

Contact Lenses?
 Yes  No

Contact Lenses to eliminate nearsightedness?
 Yes  No

Payment Information

Method of Payment Today

 Cash Check Mastercard/Visa/American Express Vision Insurance Major Medical Insurance

Insurance Company 

Digital Signature

By typing my name in the text box below, I am validating that all of the above information is accurate and up-to-date.

Digital Signature