Triage Form
Please provide additional information below to help us provide the best care and determine the urgency of your concerns. After completing, our team will contact you to schedule or collect more detailed information if needed.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Birth
Are you a current patient of Eastern Virginia Eye Associates?
*
YES
NO
Which best describes your condition/concern?
*
Eye Irritation or Pain
Pink Eye/Red Eye
Eye Discharge/Crusting/Mattering
Watery Eyes
Blurry Vision
Flashes/Floaters
Something in My Eye
Dry Eyes
Bump on Eyelid
Eye Injury
Out of Contact Lenses
Other
Which eye has the condition?
*
Right Eye
Left Eye
Both Eyes
How long ago did it start?
*
Today
1-3 day ago
3-7 days ago
Over a week ago
Since starting, it has gotten:
*
Better
Worse
About the same
Which best describes your blurry vision?
Out of focus (Distance)
Out of focus (Near)
Distorted vision
Darkening or Dimming of Vision
Spots in Vision
Have these changes appeared suddenly or gradually?
Suddenly
Gradually
Scale of 1 - 10 How bad is the eye pain / irritation?
1-2 (Not very painful)
3-4
5-6 (Moderately Painful
7-8
9-10 (Very Painful)
Do you have a prescription?
Yes, I have a valid prescription.
Yes, but my prescription is expired
No
Are there any additional details you would like to let us know?
Thank you for providing this important information.
Our doctors and team will review this information and contact you as soon as possible. If this form is received during normal business hours, we will contact you the same day. Our normal business hours are Monday through Friday 8am-5pm EST. If this form is received before or after normal business hours, we will contact you as soon as normal business hours resume. If this is a vision threatening or life threatening emergency, we recommend you seek care immediately at your nearest emergency department.
Submit
Should be Empty: