Please read. There is no need to bring this letter to your visit unless you have further questions for Dr Kirschner. Thank you.

Please fill out these two pages in their entirety. The doctors reference these pages during your examination and they would like to have everything as accurate as possible. Thank you.

Please sign this form if you are or are not having a refraction during your visit.It is stored for future use should you choose to have your vision checked for a new or updated prescription for glasses.

Please print and sign.