• Patient Appointment Form

    Welcome to Dr. Teles' Office & Looking Glass Optical
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  • Patient Information

    Fill the form below indicating the appointment type you need. We will get back to you soon for follow-up/confirmation.
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  • VERY IMPORTANT! NEW PATIENTS ONLY:


  • Insurance Information

    Please note that most insurance does NOT cover the Contact Lens Follow-Up or the CL Evaluation.
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  • Lifestyle Questions


  • The information in this confidential case history form is critical to the evaluation of your vision and health.

  • Patient Medical History

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  • Have you ever been diagnosed or treated for the following health problems?

  • Patient Eye History

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  • Family Medical/Eye History (Select all that apply)

    Is there a family medical history of any of the following:
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  • Please be advised if you are using insurance coverage for your visit, this is a contract between you and your insurance company, not Looking Glass Optical or Dr. Mayer Teles.

    If your insurance company has not reimbursed our office in full within 60 days, you are responsible for providing payment in full to Looking Glass Optical.

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