Office of Dr. Kosta A. Koutoulas, O.D.
We look forward to working with you in maintaining your eye health! Please fill out this form and submit before arriving to your visit.
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Correo *
Date of Exam
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Patient's First Name *
Patient's Last Name *
Patient's Date of Birth *
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Sex of Patient: *
Phone number *
Street Address *
City & State *
Zip Code *
How did you hear about us?
Occupation/School Name: (Helps us know your visual needs) *
Children 6-17 years old at home? Are you interested in myopia control consultation for child?
Name of Spouse
VISION Insurance Name (e.g. VSP, MES...)  *
VISION Insurance  ID # : *
VISION Insurance Primary Subscriber Name and last four digits of Social Security #: *
HEALTH Insurance Name (ie. Blue cross, Kaiser)   *
HEALTH Insurance ID# *
HEALTH Insurance Primary Subscriber Name, Social Security # and DOB *
Date of Last Eye Exam *
Do you wear glasses? *
Obligatorio
Are you interested in refractive surgery (ie. Lasik, IntraLasik, WaveFront)? 
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Do you use contact lenses? If yes, how are they working for you?
Please check if your family has history of any following diseases: 
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Obligatorio
Please check if you have a history of any following diseases:
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Obligatorio
Eye symptoms or complaints at this time: (example: dry eyes, burning eyes, itchy eyes..etc) *
Previous eye diseases or surgeries: *
List of medications (including eye drops): *
List of any drug or medical allergies: *
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