Patient Intake Form Page

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Patient Intake Form Page

Please fill out the eye care patient intake form below:

Please know that if you are a new (or returning) eye care patient, please fill out the following form for us. It helps us identify your issues and will save you time during your eye exam. If you have any questions regarding this form, please feel free to contact us directly.

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Special Offers

Inquire with our staff or contact us for special offer details:

Free Eye Exams for Kids and Seniors

Free Eyeglasses Lenses for Kids & Students

30% Off All Eyeglass Lenses (including Nikon, Zeiss and Essilor Lenses)

Only $99 for a Full Pair o Basic Single Vision Eyeglasses

40% Off a 2nd Eyeglass Pair of Equal or Lesser Value

$30 Off a 2nd Sunglass Pair of Equal or Lesser Value

Patient Intake Form Page

Please fill out the eye care patient intake form below:

Please provide the name and basic information of the patient:

What is the primary reason for the visit to our clinic? Issues? Problems? Concerns?

Is the patient a child, adult or senior?

Has your child had an eye exam with us before?

Has the child eye care patient had an eye exam with us before?

Have you had an eye exam with us before?

Since your child is a returning eye care patient, please simply give us an update on their situation. Has anything changed? Is there anything we should know about in terms of their current health or condition of their vision/eyes? (see below)

Since you are a returning eye care patient, please simply give us an update on your situation. Has anything changed? Is there anything we should know about? (see below)

What is your occupation?

Has the patient had an eye exam before?

Is the eye care patient under the care of an Ophthalmologist (eye specialist / eye surgeon)?

Does the eye care patient wear eyewear in some form?

What type of eyewear is being worn/used?

Are contact lenses currently being worn?

Tell us how you wear your contact lenses:

Does your child currently wear contact lenses?

How many hours a day does your child use the following devices:

How many hours a day are the following devices used?:

Is your child currently taking any medications?

Has your child had any allergic reactions to medications? If so, what medications?

Have you had any allergic reactions to medications? If so, what medications?

FAMILY HISTORY - Please indicate what conditions exist with any of your blood relatives:

Has the child patient had any of the following:

Does the child patient have any of the following:

Is the child patient currently a student in school?

Does the child patient do any of the following:

What was the length of pregnancy for your child?

What was your child's birth weight?

How was the child doing immediately after the birth?

Was any medication prescribed in the first year of this child's life?

At what age did the child first do the following?

How did you hear about our office?

Please CONSENT and SUBMIT YOUR INFORMATION below

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