562-431-1301 or 714-840-9877

Beach Vision Center

10900 Los Alamitos Bl.
Suite #102
Los Alamitos, CA 90720
1 Block North Of Katella

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American Optometric Association
 
American Academy of Optometry

Most Vision Insurance Accepted Including VSP, Medical Eye Services, & Davis

Brand Name Eyewear:

Maui Jim
Nike
Oakley
Calvin Klein
Christian Dior
Guess

Beach Vision Center - Survey

Patient Name
Date
Phone
E-mail Address
Bold = Required field
If you would like more information on the following please check
Contact Lenses
Refractive Surgery
Occupational Lenses/Frames
Sports Lenses/Frames
Lens/Frames/Advances
Dry Eye Treatment
Vision and Computers
Sports Vision
Infant Vision Care
Vision Therapy
Lazy or Cross Eye Treatment
Vision and Reading Problems
Glaucoma
Cataract Care
Retinal or Macular Disease
Are you interested in laser correction for nearsightedness?
Do you work on a computer?
Are you sensitive to sunlight?
Does driving at night bother you?
Is preventative eye care important to you?
Please check off any special requirements you may have or any activities in which you engage. Your eyewear needs.
Daily Wear
Dress Up
Driving
Sunglasses
Sunglasses that Change
Business
Sports
Reading
Other
Hobbies You Enjoy
Home Workshop
Stamp or Coin Collection
Driving
Drawing/Painting
Needlework/Knitting/Etc.
Bridge of other Card Playing
Reading Only
Sports In Which You Participate
Racquetball/Tennis
Boating
Contact Sports - Football
Jogging Or Cycling
Scuba/Swimming
Hunting/Shooting
Skiing
Golf
Other
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