Eyelash Lengthening Visit

You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:
- Severe or unusual chest pain
- Severe shortness of breath
- Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
- Thoughts of harming yourself or others
ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*

Yes, I am having an emergencyNo, I am NOT having an emergency

Have you ever had glaucoma (increased eye pressure)?*

YesNo
Within the last four weeks, have you had an eye injury?*

YesNo
In the past year, have you had eye surgery or Lasik?*

YesNo
In the next three months, are you planning to have eye surgery or Lasik?*

YesNo

Do you have any medication allergies?*

YesNo Known Drug Allergies (NKDA)
Please list your medication allergies:*
Are you currently taking any medications?*

YesNo
Please list your current medication and dose below (i.e. Wellbutrin XL 150mg tab)*
Are you pregnant?*

YesNoNot sure
Are you breastfeeding?*

YesNo

Would you like to add any additional information or questions for the provider to see?*

YesNo
Add additional information below:*

PHARMACY INFORMATION