Patient Info Form

Patient's First Name:

Patient's Last Name:

Date of Birth:

Sex:

Male Female

Patient status:

New Returning

Vision insurance/insurance (if any):

Insurance ID number:

Secondary insurance (if any):

Insurance ID number:

Address:

City:

State:

Zip code:

Work phone:

Home phone:

Cell phone:

Text OK:

Yes No

Email:

Occupation:

Employer:

School attending:

Student ID:

If student, permanent address:

Emergency contact:

Relation:

Phone number:

Referred by:

Other family members seen here:

Date of last eye exam:

Dilated?

Yes No

Do you wear...?

Please note: Contact lens exam fees may not be covered by insurance

Glasses Contacts Both None

Allergies (if any):

Do you feel your vision has changed since your last exam?

Yes No

What is your general health?

Do you have high blood pressure?

Yes No

Do you have diabetes?

Yes No

If yes, what type?

Date of diagnosis:

Allergies to medications?

Yes No

Which?

Reactions?

Other health problems:

Current medication(s):

Family doctor:

Date of last physical:

Under current care?

Yes No

Does anyone in your family have high blood pressure?

Yes No

Relation:

Does anyone in your family have diabetes?

Yes No

Relation:

Does anyone in your family have glaucoma?

Yes No

Relation:

Does anyone in your family have macular degeneration?

Yes No

Relation:

Does anyone in your family have retinal detachment?

Yes No

Relation:

Does anyone in your family have cataracts?

Yes No

Relation:

I have read and understand the Urban Optics Privacy Notice

Purpose of Appointment:

“I can't say enough wonderful things about Urban Optics. Their frame selection is unbeatable, Dr. Schultz always gets my prescription just right, and their staff is not only knowledgeable but really cares about you. I'm always smiling when I leave their office. Thank you!”

- Tracy W.

“Great staff. Fantastic selection of frames that is constantly evolving. Although most of the frames can get a bit pricey, they have a good selection of affordable frames as well. Trust the staff when it comes to picking the right frames for your face. In the 13+ years I've been going to UO, they have never led me wrong.”

- David L.

“While I (unfortunately) did not get my eye exam with UO, I did get my prescription filled here. Hanna helped me out, she was very friendly and helpfully and as I found out, the daughter of Dr. Dave, the optometrist and owner. Hanna was very patient and accommodating, she helped me find a frame that I liked and set me up, the process was a breeze. Susan helped me out when I came back to pick up my glasses, she had me try them on and made proper adjustments to them and offered some tips for care of my frames/lenses.I had a wonderful experience with Urban Optics and look forward to continuing my business with them in the future.”

- Jason Y.

“My wife and I recently switched over from another Optometrist in Pismo. Really happy we did. The staff is really knowledgeable and nice. They are really helpful answering questions. Really liked Dr. Schultz as well. He really seems to know what he is doing. All his equipment seems clean and very up to date. Really happy with our new optometrist.”

- John K.

“This is by far the best place to go for an eye exam and glasses on the central coast, and I've been to a few others. Really excellent, well trained staff; Dr. Schultz is thorough, positive, cheerful! They remember you from year to year, it's like you're part of the family. I always come out of there feeling like I've had a great exam, and with top notch, stylish eyewear. Prior to my recent visit, I received an email the day before reminding me of my appointment, then I got a text message an hour and a half before my appointment reminding me of the appointment. Great updated equipment, too.”

- Susan C.

“They really helped me get the glasses that make me look good! Are they more expensive than other places in town--maybe, but guess what--you only get one chance at a first impression, and if that impression is that my glasses make me look like a dork, well I just can't afford that!”

- Timothy T.

“Best eye exam ever! Never thought I'd say that. Dr. Schultz was really good and super laid back ...he reminds me of Brad Pitt meets San Juan Capistrano (if that makes any sense). The office staff were great from setting up appointments, to being so nice when I was running behind, to helping me pick out my new frames. I love my new frames! In the past I've bounced from eye doctor to eye doctor because they were all Almighty's deserve better than alright. So, I'll be keeping Urban Optics and be bouncing no more.”

- Krista P.

“Love the entire office. Their use of social media (at your request) makes appointments and reminders easy. The best part? I GUARANTEE I will come out with glasses that fit my face, I'm super happy to put on everyday, and I get weekly compliments. The staff is always friendly, very knowledgeable. Why would you go anywhere else?”

- Hayley T.

“I have a great experience every time I stop in. I highly recommend Urban Optics as the best Optometrist in town. The staff is incredibly helpful and always friendly. I have never had an appointment where I was waiting to see Dr. Shultz, see as how he is very prompt at seeing me at my scheduled time. Also, the frame selection is great and I love that they stay on top of the latest trends!”

- Kristene C.

“Such a hip place and the knowledge to go right along with it. Dr. Schultz has had to treat several eye issues for me and all have healed up beautifully. I have a lot of confidence in his medical ability because of this I will not go to any other eye Dr. in this area. The staff is so accommodating and environment of the lobby is so comfortable, it is a pleasure to come to this business! What else can one ask for anyway!”

- Elizabeth W.

“I couldn't be happier with Urban Optics. I'm a first time patient there. From the time I walked in to schedule my appointment to the exam to the day I picked up my new glasses...everything was handled professionally, friendly and quickly. AND I'm a huge fan of the text message appointment reminders!”

- Karen S.