WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Follow Us

303-659-3036
 

GENERAL MEDICAL HEALTH HISTORY AND EYE HISTORY QUESTIONNAIRE-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!

FAMILY MEDICAL HISTORY TO INCLUDE BLOOD RELATIVES ONLY (NOT YOUR SPOUSE PLEASE)

CONTACT LENS PATIENTS ONLY FOR THIS FINAL SECTION

Note to Contact Lens wearers. PLEASE bring your contact lens boxes or packaging with you so we may know what you are currently wearing! This saves you expense because it saves us time! Thanks, Dr. Fair and Dr. Baker.

undefined