Let's get to know each other. 


Name *
Name
Date of Birth
Date of Birth
Address
Address
Primary Phone
Primary Phone
Secondary Phone
Secondary Phone
Preferred Method of Contact *
Tell us the best way to reach you.
Our eyes are also working! Please tell us what you do for work.
Please describe your job duties to us.
If you do not currently have a Family Doctor, let us know.
Family Doctor Phone Number
Family Doctor Phone Number
Insurance Information *
Do you have insurance?
Do you have dependant coverage?
Have you ever been treated for... *
We will keep track of your medical history.
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Purpose of your visit with us. *
Check all that apply.
How did you hear about us? *
We want to know!
Do you wear the following? *
Check all that apply.
What do you use all of the time?
Your answers to these questions will guide us in recommending the best products to meet your eyewear needs.
For Reading/Working:
For Driving:
For Sports or Outdoor Recreation:
Which do you do regularly?
Check all that apply.
Spend time at the cottage in the summer? Read a lot by the water? Spend time sewing or golfing? Maybe you are on tour with your band? We would love to know how YOU keep busy!
What is important when choosing your new glasses?
Please check all that apply.
Can we stay in touch? *
At Advanced Vision, we take pride in building authentic relationships to provide a customized experience that meets your needs. In order to serve you better, we are asking for your approval to build a relationship with you via email and share the following information with you: Trunk Shows – Events that feature exclusive new and upcoming brands Promotions – Exclusive friend’s and family opportunities to save If you wish to receive this information and consent to us sending you this information by email or other forms of electronic communication, please check the box below. It is our promise to you that we will not abuse this privilege.
PLEASE BRING THE FOLLOWING TO YOUR EXAM:
YOUR CURRENT GLASSES & SUNGLASSES. A LIST OF CURRENT MEDICATIONS.