Complete Eye Exam Form

This form helps our doctors prepare for your exam by letting them know about any potential issues you may be having with your eyes. Complete it at your own convenience prior to your appointment so our team can help you achieve healthier eyes and clearer vision.

Complete these 2 easy steps for a smooth check-in for your appointment.

  1. Fill out and submit this form online
  2. Download and fill out the “Acknowledgement of Notice of Privacy Practices” form, and bring it with you to your appointment
Name(Required)

Do you ever experience any of these eye-related symptoms?

Dryness, Burning, Tearing, Redness, Itching, Fatique, Scratchy or Gritty Sensation.
If YES please answer the following five questions and rate your symptoms based on a scale of 0-4
1. My eyes are Dry, Gritty and Scratchy(Required)
Please rate your symptoms based on a scale of 0-4.
2. My eyes are sore and irritated(Required)
Please rate your symptoms based on a scale of 0-4.
3. My eyes burn or water(Required)
Please rate your symptoms based on a scale of 0-4.
4. I experience eye fatigue(Required)
Please rate your symptoms based on a scale of 0-4.
5. My eyes are red(Required)
Please rate your symptoms based on a scale of 0-4.

Are you interested in contact lenses?(Required)
Do you currently wear contact lenses?(Required)
Are they comfortable?(Required)
What do you wish was better about your contact lenses?(Required)

This field is for validation purposes and should be left unchanged.

DOWNLOAD AND FILL OUT THE “ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES” FORM, AND BRING IT WITH YOU TO YOUR APPOINTMENT!

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