d r/so/u
DR. DOUGLAS CREGER, OPTOMETRIST
Welcome to our office! Our staff will be very happy to assist you with all or part of this form.
Date of Last Exam
Today's Date
Insurance Information
Patient Information
Vision Insurance
Subscriber Name
Last Name
Subscriber SSN
MI
First Name
Subscriber Birth Date
Mailing Address
City
State
Date of Birth
Age
Primary Medical Insurance
ZIP
Sex
M
F
Subscriber Name
Patient's SSN
Subscriber SSN
Home Phone
Subscriber Birthdate
Work Phone
Is there secondary medical insurance?
Cell Phone
Do you participate in a flex spending account? Y N
Email Address
How will you settle your account today?
Allow do
Y
N
OCash 0 Check OCredit Card
you prefer to be contacted?
w(Please indicate first and second choice)
Home 0 Work 0 Cell 0 Text 0 Email 0
Lifestyle Questions
Spouse (or Parent's) Name
Spouse (or Parent's)Work
Do you. ..(Check if answer is yes)
Your Employer (or School)
Your Occupation (or Grade)
Owork at a computer?
Retired Y N
Othink you might benefit from thinner, lighter
lenses?
What is the major purpose of this
Ohave an interest in trying contact lenses?
visit?
0 spend time outdoors? How much? Hrs/week
Any problems with your current contact lenses or
Ohave prescription sunwear?
glasses?
Owant information on Laser Vision Corrective
Surgery?
Whom may we thank for referring you to our
office?
Elhave more that 1 pair of current RX eyewear?
Ohave children?
Name of friend/relative/doctor
If not referred, how did you choose our office?
0 Insurance
Ohave family members in need of eyecare?
0 Yellow Pages
Li Saw sign/building
D Newspaper/Radio/TV
Web Page-Which Site?
If you are a student please list your permanent
address:
er
Mailing Address
City
P.O. BOX 27, 233 E. GLENDALE • DILLON
State
Zip
MT 59725 • T: 406-683-2611 • F: 406-683-2676 • W: www.visionsource-drcreger.com