The Eye Gallery and Artful Eye - Atlanta, GA and Northwest Florida

September 2010

Just because it is cooling down doesn't mean the harmful rays are gone. If you have worn out your sunglasses this summer come in and check out our collection. We carry all the top performance lenses and frames in Atlanta and Northwest Florida. We urge you to try on the latest models of Kaenon, Oakley, Costa del Mar and Maui Jim. These designers continue to perfect technology in their lenses for the ultimate eyewear.

October 2010

Our Fall collection is already in the store and the lines are looking sophisticated and fabulous. Jewel tones and plastics are paving the trends for this fall. Try some of our new frames with a little splash of color to brighten up your image. Check out our online coupon for special offers when visiting any of our locations.

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PATIENT INFORMATION

Patients Full Name:
if patient is under the age of 18 parent or guardian name is needed.
Parent /Guardian Name:		Age:
Contact Phone #:
E-mail:
Location:
For same day appointments please call store.

Previous patient?	Yes	No
Do you currently wear prescription glasses?	Yes	No
Do you currently wear contact lenses?	Yes	No
Exam for:	Glasses	Contacts	Both

APPOINTMENT DATE AND TIME*

1st CHOICE:

2st CHOICE:

INSURANCE INFORMATION

Insurance Provider:
Member ID #:
Member's Name:
(If different than patient's name)
Date of Birth:

* We can only accommodate same day appointments by phone. The on-line appointment option of our website is for routine appointments ONLY and NOT emergencies.

EMERGENCY CONTACT INFORMATION
If you are experiencing a significant problem/medical eye emergency (loss of vision, sudden change of vision, unusual eye pain, eye trauma, fainting or dizziness) call a store location immediately!

AFTER HOURS (call our affiliate):
OMNI EYE SERVICES - 404.257.0814
Omni has a 24/7 answering service with a doctor on call.

NOTE: Patients CANNOT call Omni for replacement contacts or prescription eyeglasses, strictly medical emergencies. If conditions worsen and become severe call 911.

DURING BUSINESS HOURS: CONTACT STORE