Merrimack Vision Care, New Hampshires premier Eye Doctors provides complete Eye Care, Eyeglasses, Contact Lenses and Vision Therapy services.

Patient Check In Form:

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Select the Office you will be visiting

I will be visiting the Manchester Office.

I will be visiting the Merrimack Office.

Your Contact Details

Labels in red are required.

Patient Name		Occupation
Street Address		City
State		Zip Code
Cell Phone		Home Phone
Email		Social Security Number
Birth Date		Todays Date
Are you currently a Patient of Merrimack Vision Care?
Would you prefer text or email notifications from our office?

Lifestyle Questions

Please select all that apply.
Biking	Skiing	Golf	Public Speaking
Tennis	Night Driving	Team Sports	Computer Use
Hiking	Boating	Gardening	Fishing

Visual Symptons

While wearing my current correctional lenses, I experience the following.
I don't wear any correctional lenses at this time and I experience the following.

I am bothered by blurry distance vision.	I am bothered by blurry close vision.
I have trouble viewing text on my computer.	I get double vision.
My eyes water or are bloodshot.	I have difficulty driving at night or in the rain.
I am visiting today for a routine eye exam.	I am visiting today for a contact lens exam.
I frequently experience headaches.	I experience floaters.

I would like to learn more about LASIK.

Insurance Plans

I am covered by Vision Service Plan (VSP).	I am covered by Eyemed Vision Plan.
I am covered by Spectera/ Optum Health.	I am covered by Superior Vision.
My Health plan is	Insurance ID Number

Medical / Visual History

Please select all that apply.
Cancer.	High Cholesterol.	Head Injury.	Heart Disease.
Diabetes.	Glaucoma.	Flashes of light.	Sudden loss of vision.
Eye Surgery.	High Blood Pressure.	Arthritis.

Family History of...
Macular Degeneration.	Diabetes.	Glaucoma.

Please list any medications you are taking.	Please list any allergies and/or drug sensitivities.