New Patient Check-in Book An Appointment Save some time before your appointment! (Scroll down to get in touch with us). Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country What eye/vision issues would you like our doctor to address with you? * When was your last eye exam? * Were you told you had any eye conditions? If so, which ones? * Do you wear contact lenses currently or are you interested in wearing contacts? * Do you have any medical conditions? If so, which ones? * Are you taking any medications/supplements/hormones/eye drops? If so, what are they? (If you have a medication list, bring it in with you so we can make a copy of it) * Do you have a family history of any eye conditions? If so, which ones? * Have you had eye surgery? If so, please list the procedure and which eye. * Do you have any known medication/material allergies? If so, what are you allergic to? * Are you pregnant/nursing? * Are there any general symptoms you are experiencing? (ie. fatigue, brain fog, headaches, unexplained weight gain/loss, menstrual changes, trouble sleeping etc.) How did you find out about us? Thank you! Contact Us Name * First Name Last Name Email * Message * Phone (###) ### #### Thank you so much! We will message you back shortly!
