Online Forms

Ocular History

If your last eye exam was NOT at our office, who did you see and when?

Do you see an Ophthalmologist (eye specialist/surgeon)? Yes No

If yes, who do you see?

Do you wear glasses? Yes No

If Yes:
Full Time Part Time Reading Only Office Only

Do you wear contact lenses? Yes No Interested

Do you wear sunglasses? Yes No

Does your job/hobby require safety glasses? Yes No

Medical History

Please check all that apply

Please list your medications or supplements below or bring a list:

Submit Adult Patient History Form