Patient Information

    Preferred method of contact? *

    Have you had an eye exam before? *

    At this location? *

    Have you had a dilated eye exam? *

    Do you wear contact lenses? *

    Are you currently experiencing any of the following?

    Flashes of light and Floaters *

    Eye Pain *

    Double Vision *

    Dry Eyes *

    Light Sensitivity *

    Poor Night Vision *

    Personal Medical History

    High Blood Pressure *

    Diabetes *

    Glaucoma *

    Age Related Macular Degeneration *

    Cataract *

    Crossed/Lazy Eyes *

    Family Medical History

    High Blood Pressure *

    Diabetes *

    Glaucoma *

    Age Related Macular Degeneration *

    Cataract *

    Crossed/Lazy Eyes *

    Covid-19 Screening Questionnaire

    Are you experiencing any signs or symptoms of COVID-19? *