Reg Form Patient Information First Name * Last Name * M. I. Date Of Birth * Phone Number * Gender * MaleFemaleOther Street Address * City * State Zip Code * County * If under 18 years of age, provide name of parent or guardian. (Enter NA if 18 or above 18 years of age) First Name * Last Name * M. I. Parent Phone * Please enter your email address below (the one you check the most often): * Please fill below information if different from above. Street Address City State Zip Code County Is your annual household income greater than $45,000.00 per year? * Yes No Do you rent or own a home? * RentOwn Do you currently wear eyeglasses? If so, please bring them to your eye exam appointment. Yes No Who is your primary employer? If unemployed, write N/A. Employer Name & Address: Employer Phone Number: Do you have insurance? * MedicalMedicaidOtherNo Are you a veteran? * YesNo Please check all the legal ethnic groups that correspond to you. * American Indian or Alaskan Native Asian Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or Pacific Islander White Referred By * Preferred day/time for appointment * Do you have any health issues? * YesNo Specify if health issues option is 'Yes' Language you speak * School District * Submit If you are human, leave this field blank.