•  /  /
    Pick a Date
  •  /  /
    Pick a Date
  • COVID-19 screening Questions

    In the last two weeks have you:
  • Note: Patient with COVID-19 symptoms or recent exposure will be asked to reschedule.



  • Eye Symptoms



    • Contact lens wearers  
    • Contact lens wearers

      If you are schedule for renewing your contacts prescription please answer the following questions.
    • Important! Contact lens wearer have your contacts on at least 3 hours before your scheduled appointment. If you have run out please call immediately.

      If you are new to the office please bring your contact lens prescription information and glasses.




    • The follow questions are for patients who do not wear dailies. (2 week, monthly, rigid gas permeable lens)



    • Medical History  
    • Medical History

      Check all that apply to you, list additional conditions in other













    • Last medical exam

    •  -  -
      Pick a Date
    •  -



    • Personal Social History: (ALL information is strictly confidential, you may discuss this part with the doctor))




    • Family Medical and Eye History  
    • Family Medical and Eye history

      Parents, and siblings with conditions below specify who and condition when appropriate.
    • Thank you for completing your medical history form.

      We look forward to seeing you soon. 

      When you arrive PARK & CALL. 

      Don't forget your mask. 

    • Should be Empty:
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