Short Update Form for Returning Patients
During the Last 3 Months, what ocular symptoms have you experienced?
Blurry Vision
Double Vision
Flashes
Floaters
Dry/Gritty Eyes
Itchy Eyes
Watery Eyes
Painful/Sore Eyes
Tired Eyes
Light Sensitivity
Red Eyes
Mucous/Crusty Eyes
Crossed/Lazy Eye
Other Ocular Symptoms:
No ocular symptoms recently
Who is your Primary Care Medical Doctor?
(Including any recent eye surgeries, diseases or injuries, or new major medical issues, or new family history)
*Click Here to Review: Patient Policies (pdf)
By clicking "Submit Data" below, you confirm that you have reviewed and agree to the policies in the document linked above.
Submitted by:
Date Completed: