Please complete the information below and submit the form online, Micihgan if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
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Please enter a value between and Employer Occupation How were you referred to our office? I stopped wearing contact lenses because: Glasses History Do you wear glasses? Please Micnigan us what other kinds of glasses you own.Italian Man On Raleigh North Carolina St
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How old are your current lenses?
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Please Micnigan a telephone number, with area code, so we can contact you. English Spanish French Japanese Decline to specify. Please Select Email Postal Telephone. I am having problems with my current glasses There are times when I would rather not be wearing glasses I have problems with glare I have problems with night vision I am allergic to nickel e.
I am having problems with my current contact lenses There are times when I would rather not be wearing contact lenses I am interested in changing or enhancing my eye color I Michiggan interested in a non-surgical method of vision correction I am interested in refractive laser surgery I don't have a spare set of contact lenses My spare contact lenses have an incorrect prescription.
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God bless you and your staff. The staff is very friendly and the doctors seem very knowledgeable.
Doctor Barden is great with children and adults. She listens and gives a very detailed eye exam. She explains each step in the process, so her patients feel relaxed and that they are in capable hands!
Kaczmarczyk and her entire staff are very professional, knowledgeable and friendly. I would recommend everyone to get their vision cared for here.
Friendly, knowledgeable, attentive, fast!
I'm so glad I found them! It makes an incredible difference in my life I called the office this afternoon after my son tore his last pair of contacts.
It's Friday afternoon and the office had just closed. Kocks went back to the office to get him an extra pair to get through the weekend.
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