Patient center New Patients

Patient center New Patients

FOR YOUR VISIT TO INSIGHT OPTOMETRY VISION THERAPY

INTAKE FORM NEW PATIENTS

In an effort to make you more comfortable when you arrive at our office and to streamline the new patient process, you will be able to complete all the necessary items prior to your first visit.

Please fill out our pre-examination form below so we are ready for your first visit.

"*" indicates required fields

Full Name*
Preferred Name:
Relationship to the patient:

Address*
MM slash DD slash YYYY
*
Preferred Method of Contact:*
May we contact you by email or text regarding information about appointment reminders, order updates, current sales and promotions:*
How did you hear about InSight Optometry*

Are you planning on using extended benefits for any portion of your visit?*
Policy Details
Max. file size: 128 MB.
Reason for eye exam:*

Do you wear:*
Current glasses:*

Contact lenses:*

Your Medical History

Eyes
General Health

Family Medical History

Eyes
General Health

1. Questions about EYE DISCOMFORT:

a. During a typical day in the past month, how often did your eyes feel discomfort?
b. When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

2. Questions about EYE DRYNESS:

a. During a typical day in the past month, how often did your eyes feel dry?
b. When your eyes felt dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?

3. Questions about WATERY EYES:

a. During a typical day in the past month, how often did your eyes feel excessively watery??
This field is for validation purposes and should be left unchanged.

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