Patient Intake
Please complete the information below. Fields marked with * are required. Please use standard capitalization for names.
Submission setup pending
This form is a preview and is not connected to a secure submission endpoint yet. Please do not enter real patient or health information until submission is set up.
Patient information
Consent and contact
Tell us who will sign the consent and how we can reach you.
Insurance information
If you know your insurance information, enter it below. You can leave details blank if they do not apply.
Other benefits
Vision and health history
Share any concerns that may help the doctor understand the patient’s needs. Check all that apply.
Vision concerns
Eyeglasses usage
School performance
Eye health
General health
Submit intake
Submission will be enabled after you provide the secure destination for the form data.
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