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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:	SELECT STORE Sandy Springs (Atlanta,GA) - 404.252.4111 North Point Mall (Alpharetta,GA) - 770.475.6500 Buckhead (Atlanta,GA) - 404.231.3772 The Forum (Norcross,GA) - 770.447.4790 East Cobb (Marietta,GA) - 770.977.4139 Atlantic Station (Atlanta,GA) - 404.593.2926 Perimeter Place (Atlanta,GA) - 770.500.3937
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:
	SELECT TIME 9:30-10:00 10:00-11:00 11:00-12:00 12:00-1:00 1:00-2:00 2:00-3:00 3:00-4:00 4:00-5:00 5:00-6:00 6:00-6:30
2st CHOICE:
	SELECT TIME 9:30-10:00 10:00-11:00 11:00-12:00 12:00-1:00 1:00-2:00 2:00-3:00 3:00-4:00 4:00-5:00 5:00-6:00 6:00-6:30

INSURANCE INFORMATION

Insurance Provider:
Member ID #:
Member's Name:
(If different than patient's name)
Date of Birth:	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec	Year 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901

* 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