Spearfish Eye Care Center

Date

Social Security Number*

Patient’s Name*

Date of Birth

Mailing Address, City, State, Zip Code

Email *

Home Phone

Cell

Marital Status

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Preferred Method of Contact

E-mail Cell Phone Home Phone Mail

Is texting okay?

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Place of Employment

Occupation

Ethnicity

Declined to Specify Hispanic or Latino Not Hispanic or Latino Native Hawaiian or Pacific Islander

Insurance

Policy #

Policy Holder's Name

Relationship

Policy Holder's Social Security Number

Date of Birth

Date of Last Medical Exam

Medical Physician

If you had your last exam here and purchased glasses here, PLEASE SKIP QUESTIONS 1 AND 2 BELOW.

1. How Old are your present glasses?

2. Date of last eye exam

If at another facility, please enter the name of your eye doctor

Do you wear contacts?

Yes No All the time Sometimes

Wearing schedule

Daily Overnight

Type / Brand of Contacts

Solution Used

Have you every had any eye injuries?

Yes No

Describe

Have you ever had any eye surgeries?

Yes No

Describe

Do you use any eye medication?

Yes No

Explain

Any Additional Eye Problems?

What is your primary visual concern today?

Please list any activities you have difficulty doing because of your eyes or eyesight?

Are you currently pregnant or nursing?

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Whom may we thank for referring you to our office?

Signature:*

Date *

Please do not submit any Protected Health Information (PHI).

Location

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Spearfish Eye Care Center

Address

1710 North Ave
Spearfish, South Dakota 57783, US

Contact Information (605) 642-8480

(605) 642-8185

[email protected]

Hours of Operation

Monday

8:00 am - 5:30 pm

Tuesday

8:00 am - 5:30 pm

Wednesday

8:00 am - 5:30 pm

Thursday

8:00 am - 5:30 pm

Friday

8:00 am - 5:30 pm

Saturday

Closed

Sunday

Closed

Welcome Form

Insurance

Location

Find us on the map

Hours of Operation

Spearfish Eye Care Center