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Envision Optique
Dr. Michael R. Obregon
Optometric Physician

We are located in the heart of Coral Gables, 3 blocks south of
Miracle Mile - facing the circle park

Our staff members speak English, French and Spanish

Call Us! (305) 440-4465 Schedule Appointment Text Us! (305) 444-9600

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Home » Welcome Page – English

Welcome to the Office

ENVISION OPTIQUE
Dr. Michael R. Obregon
Board Certified Optometric Physician

Please fill out this form as completely as possible. Once you have completed the form, click "Submit." Your information will be received securely and we'll have it ready when you come in.
GENERAL INFORMATION
Full Name:*
First Last
Sex:*
- Male
- Female
Date of Birth:*
Employer:*
Occupation:*
Primary Ph #:*
Secondary Ph #:*
Email Address:*
Preferred Method of Contact*
- Phone
- Text
- Email
Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
MEDICAL HISTORY
Please list any medical conditions now or in the past:*
Please list current medications (including birth control, hormones, eye drops, supplements):*
Name of Primary Care Physician:*
Ph #:*
Date of Last Physical:*
MEDICAL SYSTEMS REVIEW*
Yes No Family
Allergies
High Blood Pressure
Heart Disease
Diabetes
Gastrointestinal (Digest.)
Cancer
Endocrine/ Thyroid
Ear-Nose-Throat
Headaches
Urinary
Blood/ Lymph Nodes
Respiratory/ Lungs
Infectious
If you selected "family" for any of the above conditions, please specify the condition and which family member below:
Condition Family member
OCULAR HISTORY/SYMPTOMS*
Yes No
Blurred Vision
Double Vision
Tired When Reading
Spots
Cataracts
Eyelid Problems
Glaucoma
Tearing
Surgery
Trauma
Heavy Computer Use
Active Sports / Hobbies
Other
If other, please specify:
Anything else we should know about?*
INSURANCE INFORMATION
VISION INSURANCE:
Name of Insurance:*
Policy / ID #:*
Are you the Primary Insured?*
- Yes
- No
If not Primary Insured – Name of Primary:
Relationship to Primary Insured:
MEDICAL INSURANCE:
Name of Insurance:*
Policy / ID #:*
Are you the Primary Insured?*
- Yes
- No
If not Primary Insured – Name of Primary:
Relationship to Primary Insured:
REASON FOR THE VISIT
Why are you here today?*
For example: contact lenses, eye problems, new glasses, routine exam, etc.
How did you hear about us?*
For example: insurance website, friend, family (please list name), social media, etc.
Does your work require special vision needs?*
- Yes
- No
Do you have persistent dryness in your eyes?*
- Yes
- No
Interested in corrective laser surgery?*
- Yes
- No
Interested in eliminating glasses without surgery?*
- Yes
- No
Activities/ Hobbies require special vision needs?
- Yes
- No
Are you interested in Contact lenses?
- Yes
- No
Are you interested in corrective laser surgery?
- Yes
- No

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Envision Optique

2726 Ponce De Leon Blvd
Coral Gables, FL 33134

Phone: 305-444-9600
Email: mail@envisionoptique.com
(Do not send personal health information by email.)

Monday: Closed
Tuesday: 10:00 AM - 7:00 PM
Wednesday: 10:00 AM - 7:00 PM
Thursday: 10:00 AM - 7:00 PM
Friday: 10:00 AM - 7:00 PM
Saturday: 9:00 AM - 2:00 PM
Sunday: Closed

Hours & Location
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Eye Care Services
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Our Eye Care Clinic
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Envision Optique - Located at 2726 Ponce De Leon Blvd, Coral Gables, FL , 33134. Phone: 305-444-9600 . https://www.envisionoptique.com

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