Patient Information Form

Parents of children: The information requested is very important. In order for your child to receive opticall care provided by our mobile Optometry Bus, you will need to complete this form for your child. This information form becomes part of our permanent record and will be held in strict confidence. Please choose Yes or No where indicated. If you are unable to complete this form by yourself, please ask for assistance. If you have questions, call us at 417-328-6730. Thank you!