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86 W Main St, Lehi Utah 84043

801-766-1696

Text us at 404-400-8864 for appointments or questions

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New Patient Information Form

New Patient Information

Please fill this form out as fully and accurately as possible to help us serve you as best as possible.

Patient Name

Date of Birth

Past Medical History

Cancer

Cataract

Crossed Eyes

Diabetes

Droopy Lid

Ear/Nose

Eye Injuries

Eye Surgery

Gastrointestinal

Glaucoma

Heart Disease

High Blood Pressure

High Cholesterol

Keratoconus

Kidney

LASIK

Lazy Eye

Lupus

Macular Degeneration

Migraine Headaches

Multiple Sclerosis

Neurological

Psychological

Respiratory

Sinus

Thyroid

Family History

Blindness

Cancer

Crossed Eyes

Color Blind

Diabetes

Kidney

Lazy Eye

Macular Degeneration

Retina Detachment

Heart Disease

High Blood Pressure

Thyroid

Glaucoma

None

Other

Eyewear History

Glasses

Bifocals

Trifocals

No-Line Bifocals

Soft Contacts

Toric Soft CLs

Rigid Contacts

Other

Allergies to Medications

Current Medications Taken

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

© 2023 by Lehi Vision Care

86 W Main St Lehi Utah 84043

Tel: 801-766-1696

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