Please fill out all information below as completely as possible. Be sure to click the "Submit Data" button at the bottom when finished to securely submit the form.

New Patient? If you are a new patient or haven't seen us in more than 2 years, please use the Full Patient Form
Want to Load Previous Data? We can load your previous information for you to just review and update, if you obtain a passcode from our office and enter at the Passcode Login
Having trouble? Call/Text 480-706-3060 or Email office@azlifetime.com

Patient Information

Ocular Updates

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



Medical Updates


  • Pregnant
  • Nursing
  • No current health issues

Other Updates

(Including any recent eye surgeries, diseases or injuries, or new major medical issues, or new family history)

Review Policies & Submit

 

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