Intake Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

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This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Insurance

Ocular And Contact Lens History

Please check any/all that apply to you

Medical History

Review Of Systems

Retinal Imaging

Retinal imaging is an advanced diagnostic tool to help detect eye conditions such as macular degeneration, glaucoma, and retinal holes, tears or detachments. It may also help identify signs of systemic diseases such as diabetes and high blood pressure.

Retinal imaging replaces dilating eye drops. Some patients may still need to have their eyes dilated. Most insurance plans cover retinal imaging with a copay of up to $39.

HIPAA Notice Of Privacy Practices Acknowledgment

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