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Midwest Eye Associates | Local Eye Exams in Charles, MO
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Existing Patient Form

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  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (cell / work / home)
  • NeverSlightModerateSevere
    Gritty or sandy sensation?
    Pain or soreness?
    Fluctuating vision?
    Occasional tearing?
    Discomfort in windy conditions?
    Itching?
  • If you currently wear contact lenses, please rate how comfortable they are: (1 poor, 10 excellent)
  • NeverFormerlyCurrently some daysCurrently everyday
    Smoke/Use Tobacco?
    Use Alcohol?
  • Please be advised if you are using insurance coverage for today’s visit, this is a contract between you and your insurance company; not Midwest Eye Associates.

    I understand that I am financially responsible for all charges whether or not paid by insurance. I understand the Notice of Privacy Practices and I have been provided an opportunity to review it. If you wish to read the Notice of Privacy Practices, it is listed on our website.
  • Date Format: MM slash DD slash YYYY