Office visit check-in form to see:

Dr. Kosta A. Koutoulas, O.D.

We look forward to working with you in maintaining your eye health!

Please fill out this form and submit before arriving to your visit

Date

First Name

Date of Birth

Last Name

Phone

Insurance information

HEALTH insurance name and ID# (ie. Blue cross,Kaiser..)

Any new ocular complaints at this time:

There is a $50 charge if you miss your appointment without 24 hour notice to our office.

I understand that I will be charged $50 if I miss my appointment without giving office a 24 hour notice

Initials

Thanks for submitting! See you soon!