Eye Site®Contact Lens Clinic                  www.eyesiteusa.com
Mailing address: P.O. Box 72
Fremont, NE  68026-0072

C. Dale Bahner, O.D.
Steven V. Jacobsen, O.D.
Optometrists
Office location: 1445 North Bell Street
Fremont, NE  68025-3534		 Voice: (402) 727-9340  Fax: (402) 727-5625
E-mail: customer@eyesiteusa.com
My current
eye doctor is:		   Your Name:  
Address:   Date of Birth:  
City/State/Zip:   Address:  
Voice Phone:   City/State/Zip:  
E-mail:   Daytime Phone:  
Fax:   Evening Phone:  
    E-mail:  
    Fax:  

* This patient has contacted our office requesting the release of contact lens information from you.
Current Soft Contact Lens Information

Base Curve Dia. Sphere/Cylindar/Axis Manuf. Series Color
O.D.            
O.S.            

Modality:

  

*Referring office, please indicate the expiration date of this patient's current prescription:_____________

Special Instructions:
Disinfecting Method:

* I authorize the release of information from my current eye care professional to Eye Site®.
   I understand that this form releases current contact lens related information only, and does
   not release any medical history information.
Date: _____________ Signed:____________________________________

customer@eyesiteusa.com