Please fill out this questionnaire carefully
EMPLOYMENT OR SCHOOL
Of all the sports you have played:
Release Of Information and Insurance Filing
Thank you for carefully completing this questionnaire. The information supplied will allow for a more efficient use of time and will enable us to perform a more comprehensive evaluation and to better meet your specific visual needs.
If at any time you have any questions or concerns regarding your vision or treatment, please do not hesitate to contact us. You may leave a message for us 24 hours a day / 7 days a week.
We request a minimum of 24 hours notice if you are unable to keep this appointment.
Please be on time for your evaluation so that we may have the maximum opportunity to evaluate your visual status.
Dr. Jared Pearson, O.D.