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Patient History Form

Patient History Form
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  • Patient History Form
 

Patient History Form

In everything we do, we aim to provide our friends, neighbors, and the surrounding community with valuable eye care and optometric expertise in a setting that is friendly, modern, and efficient.

Patient Registration Form

  • Patient Information

  • Personal Information

  • MM slash DD slash YYYY
  • Please enter a number from 0000 to 9999.
    (last 4 digits only!)

  • Eye History

  • Glasses History

  • Contact Lenses History

  • Medical History

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY

  • Primary Insurance

    Please bring all insurance cards with you to your appointment.
  • MM slash DD slash YYYY

  • Secondary Insurance

    If you have coverage through another plan/organization, please fill in the details below.
  • MM slash DD slash YYYY

  • Comments

  • Privacy Policy

CALL US

(208)265-4140

Hours of Operation

Monday - Friday: 8.00 - 5.00
Saturday: Closed
Sunday: Closed

Schedule an Appointment

SANDPOINT OPTOMETRY

Established in 1991, Sandpoint Optometry has many years of experience in providing exceptional and compassionate care for all your vision needs here in Sandpoint, Idaho.

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HOW TO FIND US

123 S. 3rd Ave. #1
Sandpoint, Idaho 83864

(208)265-4140

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