Emergency Appointment Form

Triage Form

Please share more detailed information to help us provide you with the best possible care and to understand the urgency of your concerns. Once you have completed this step, our team will reach out promptly to schedule an appointment or gather any additional information if necessary.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of Birth
Gender*
Phone Number*
Please enter a valid phone number
Email*
example@example.com
Are you a patient of Yuni Eyecare?*

YesNo
Which best describes the issue you are currently experiencing?*

Something in My EyePink/Red EyeFlashes/FloatersEye InjuryBump on EyelidWatery EyesEye Pain/IrritationEye Discharge/Crusting/MatteringOther
Which eye is affected?*

Right EyeLeft EyeBoth Eyes
When did it start?*
Since it began, has it improved?*

YesNoSame
Do you have any other information to share with us?
Thank you for providing this important information with us.

Our team will thoroughly review this information and will contact you as soon as possible to address your needs. If we receive this form during our regular business hours (10:00AM to 6:00PM, except Wednesdays and Sundays), you can expect to hear from us on the same day. However, if this form is submitted outside of our business hours, we will make it a priority to reach out to you as soon as we reopen. For any urgent vision concerns or life-threatening issues, we strongly recommend that you go to your nearest emergency department immediately for assistance.
HIPPA Consent*

This form may contain sensitive Personal Health Information (PHI) which is protected under the HIPAA Privacy Rule established in 1996. Rest assured that this information will be transmitted securely via encrypted email directly to your doctor for their review. By clicking to accept this agreement, you are giving your consent to the transfer and handling of this important information.
Should be Empty:

Triage Form