Patient Registration Form

Patient Registration

Thank you for choosing Lakhani Vision Care, PC as your primary eye care provider! Please complete the form below prior to your exam.
If you are new to the office, please bring your glasses and contact lens boxes with you.

Our office does not provide the pupillary distance (PD) with your eyeglass prescription. That will be measured by your dispensing optician.
For Office Use Only: NP/EP ___ | GLS/CLE | OM / Dilation | Reschedule Dilation | Ins:_________________ | Date:_____________
Name*

First NameLast NameSuffix
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*
MM/DD/YYYY
Sex*
Phone Number:*
E-mail*
example@example.com
Occupation

Contact Lens Fitting/Evaluation Policy

Please fill in the form below
The state of Georgia requires that a contact lens fitting be performed every 12 months to update contact lens prescription, in order to maintain eye health.

This applies to all patients, even if you may have worn contact lenses in the past or if the prescription does not change.

Contact lens prescriptions will be released to the patient upon completion of the fitting process. The fitting fee includes follow-up visits for up to 2 MONTHS from the initial evaluation regardless of lens type or modality. If follow-up visits are needed after 2 months, additional office visit charges may apply.
I give consent to have a contact lens fitting/evaluation and understand that the fee may vary depending on the type of evaluation.*

YesNoI do not wear contact lenses.
Signature*

Clear
Should be Empty:

Patient Registration