STANLEY J. HALLOCK OD
HOME
OUR SERVICES
ABOUT US
INSURANCE
RACE CARS
OFFICE FORMS
LINKS
CONTACT US
GENERAL EXAM
Call Us Today!
(407) 277-1140
Call Us Today!
(407) 277-1140
General Exam
Contact Us
Free Text
Name:
First Name
Last Name
Phone Number:
Free Text
Home Address:
Street
Second Line
City
Zip Code
Country
Please select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern &, Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island &, McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia &, South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Kosovo
Croatia
State
Please select
Ashmore and Cartier Islands
Australian Antarctic Territory
Australian Capital Territory
Christmas Island
Keeling Islands
Coral Sea Islands
Heard Island and McDonald Islands
Jervis Bay Territory
New South Wales
Norfolk Island
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Age
Date of Birth:
Social Security Number:
Name and Ages of Children:
Name of Spouse (or parent):
Where Employed:
Occupation:
Work Phone:
Cell Phone:
Email:
What do you have to see in your work?
Method of Payment:
Please select
Local Check
Cash
Visa
Mastercard
AMEX
Debit
Do You have Insurance Coverage?
Please select
Yes
No
If so: Insurance Name:
Family Physician:
How Would You Rate Your General Health?
Please select
Good
Fair
Poor
Do You Wear Glasses?
Please select
Yes
No
Do You Wear Contacts?
Please select
Yes
No
Date Of Last Eye Exam
Referred By:
What is your main reason for seeing the doctor?
Special Activities or Intrests:
Check all that apply:
Vision blurred at a distance
Vision blurred when reading or at a close distance
Vision interferes with work or activities
I have bad headaches
I am blothered by eye strain or discomfort
My eyes itch, sting, burn, water or get red
Double Vision
Sunlight bothers me
I have trouble seeing clearly at night
I have had an eye infection before
I have had an eye injury or surgery
Colorblind
I have health problems
I take medication every day
I have allergies
I have had reactions to medication or shots
I am currently under emotional strain
My blood pressure is normal
I have had a thyroid issue
I have been told I have diabeties
Have a family history of diabetes
Have a family history if of blindness
Have a family history of glychoma
Have a family history if cataracs
Have history of crossed or turned eyes
Have history of lazy eyes in out family
Default label
Please select
First choice
Second choice
Remarks or Questions
Thank you for contacting us.
We will get back to you as soon as possible.
Oops, there was an error sending your message.
Please try again later.
Site Map
HOME
OUR SERVICES
ABOUT US
INSURANCE
RACE CARS
OFFICE FORMS
LINKS
CONTACT US
Content, including images, displayed on this website is protected by copyright laws. Downloading, republication, retransmission or reproduction of content on this website is strictly prohibited.
Terms of Use
|
Privacy Policy
Share by: