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Home » New Patient Intake Form

New Patient Intake Form

  • If you're new to our office, please fill out the form below so that we can get to know your ocular and medical history a bit better.
  • PERSONAL DEMOGRAPHICS

  • MM slash DD slash YYYY
  • OCULAR HISTORY

  • YesNo
    Burning/itching
    Dryness
    Redness
    Sandy/gritty feeling
    Tearing/watering
    Blurred vision
    Distorted vision
    Double vision
    Peripheral vision loss
    Tired/strained eyes
    Eye pain/soreness
    Flashes/floaters
    Glare/light sensitivity
    Mucous discharge
    Styes/chalazion
  • MEDICAL HISTORY

  • Max. file size: 31 MB.
  • SelfFamilyUnsureN/A
    Vision Impairment
    Cataract
    Colour Vision Deficiency
    Glaucoma
    Keratoconus
    Strabismus
    Diabetic Retinopathy
    Macular Degeneration
    Retinal Detachment
    Dry Eyes
    High Blood Pressure
    Cancer
    Diabetes
    Heart Disease
  • This field is for validation purposes and should be left unchanged.