Prospective Patient Info Form
(Please fill out as much info as possible)
*Name:
*Address:
*City:
*State:
*Zip:
*E-mail:
Phone:
"*"Denotes Required Fields
1. Are you at least 18 years old?
2. Has your vision been stable for at least one year?
3. Are your eyes free from cataracts, glaucoma, infections?
4. Are you pregnant or nursing an infant?
5. Did you wear glasses before the age of 40-50?
6. Do you need glasses only for reading small print?
7. Do your glasses or contact lenses bother you?
8. If you lost your glasses or contacts, and didn't have another pair with you, would you be upset?
9. Are you unable to wear contacts?
10. Would you like it if when you wake up you could immediately see the alarm clock and other things clearly?
Would you like a FREE consultation with Dr. Tyson personally?

If you know your prescription, please complete the next section.

My prescription is OD (right eye)
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Cylinder:
Axis:
My prescription is OS (left eye)
Sphere:
Cylinder:
Axis:

 


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