Type in the boxes to complete the history and then click the submit button at the bottom to email this form.

PATIENT SAYING TO THEMSELVES: BUT YOU HAVE THIS! WHY do I need to do this AGAIN? Information changes and we want to provide the best possible eye examination and we need the updates. Mostly it is because the Federal Government and your Insurance Company will not pay the claim without it! Dr. Fair and Dr. Baker do not like unnecessary paperwork either but without this you would have to pay the bill yourself and that would not be any fun! The doctors appreciate your patience and completeness in this annual task. Thanks!