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3625 STAR RANCH RD, COLORADO SPRINGS, CO 80906 CALL 719-394-3939 FAX: 719-394-3939

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*First name

*Last name

*Birthday

Month

Day

Year

*Email

*Phone

*Address

Reason for your visit?

Glasses Prescription

Contact Lenses Evaluation

Eye problem

Other

Do you have any of these diagnosis?

Dry Eye Syndrome

Allergies

Cataracts

Macular Degeneration

Retinal Defects

Diabetic Retinopathy

Glaucoma

Other

Are you having any of the following eye concerns?

Blurry vision

Eyestrain

Headaches

Night Glare

Poor night vision

Sensitivity to lights

Total loss of vision

Redness

Itching

Burning

Tearing

Discharge

Eye pain

Other

Check any complains that you are experiencing while wearing glasses or contacts.

Distance

Near

Computer

Any injuries or surgeries to your eyes?

Do you smoke?

Do you drink

If you wear contacts: What brand and what power?

Do you use the computer or phone for extended periods of time?

Do you have any of the following health conditions?

High Blood Pressure

Diabetes

High Cholesterol

Cancer

Congestive Heart Failure

Asthma

COPD

Hyperthyroidism

Hypothyroidism

Depression

Anxiety

Bipolar

ADHD

Multiple Sclerosis

Other

What medications do you take?

Do you have any medication allergies?

Family Medical History

Mother

Father

Bother

Sister

Daughter

Son

*Please upload your Medical (Health) Insurance Cards and Supplements. (NOT YOUR VISION INSURANCE). Front and Back

*Vision Insurance:

*Primary Holder of Insurance: Name/DOB/ SSN

*I have read and understand the terms and conditions of the office and the HIPPA Notice of Privacy Practices. I also understand that I am financially responsible for all the charges whether or not they are paid by my insurance.

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Schedule your Appointment

SCHEDULE ONLINE

CALL 719-394-3939

CONTACT INFORMATION

info@bauereyecare.com

billing@bauereyecare.com

PHONE: 719-394-3939

FAX: 719-394-3939

3625 Star Ranch Rd

Colorado Springs, CO 80906

HOURS OF OPERATION

Monday 8:00am - 5:00pm

Tuesday 8:00am - 5:00pm

Wednesday 8:00am - 5:00pm

Thursday 8:00am - 5:00pm

Friday 8:00am - 1:00pm

Saturday Closed

Sunday Closed

CLOSED FOR LUNCH FROM 12-1 PM

Same-day appointments when available.

For life-threatening emergencies, call 911.

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