PATIENT INTAKE FORM

1. What is the reason(s) for your visit? Pleae select all that apply. Required

Routine/Annual Eye Examination

Eye Problem

MTO/Driver's License related Examination

Soft Contact Lens fitting & prescription

Shop for Eyeglasses/Sunglasses/Safety glasses

Ortho-K/Dream Lens Consultation

RGP or GP Contact lens service including fitting & purchase

Laser Surgery Consultation and Evaluation

Vision Therapy

Other

3. What type of eyeglases do you own? Please select all that apply.

4. Do you have any medical codition(s)? If yes, please select all that apply:

EYEWORLD