Patient Intake Form Corpus Christi

Patient Intake Form Corpus Christi
Please complete this form to help us gather necessary information for your Serum Tears treatment.
Patient's First Name*
Patient's Middle Name (Optional)
Patient's Last Name*
Birth Date

MonthDayYear
Gender*

MaleFemaleOther/Prefer not to say
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Street Address*
Apartment/Suite/Unit (Optional)
City*
State/Province*
Zip Code/Postal Code*
Please select the primary diagnosis(es) related to your need for Serum Tears (Select all that apply):

Severe Dry Eye Disease (DED)Sjögren's Syndrome related Dry EyePersistent Epithelial Defects (PED)Corneal Ulcers/ErosionsFilamentary KeratitisNeurotrophic KeratopathyPost-LASIK/PRK Dry Eye SyndromeGraft-versus-Host Disease (GVHD) related Ocular Surface DiseaseStevens-Johnson Syndrome (SJS) related Ocular Surface DiseaseLimbal Stem Cell Deficiency (LSCD)Other (Please specify below)
Other Diagnosis (If 'Other' was selected above)
Do you currently have a valid prescription from a doctor specifically for Serum Tears treatment?*

Yes, I have a valid prescription.No, but I understand I do not need a prescription for Your Serum Tears
Referring Doctor's Full Name (If applicable)
Referring Doctor's Phone Number (If applicable)
Are you allergic to any medications?

YesNo
If yes, please list the medication(s) and describe the reaction:
How did you hear about us?*

Google SearchTelevision (TV) AdvertisementFacebookInstagramTiktokReferring Doctor/ClinicFamily MemberFriendOther
If 'Other' was selected above, please specify:
Should be Empty: