Patient Intake Form

Personal Information

*First Name:
*Last Name:
Email:
Age:
City of Residence:

Medical History

Do you suffer with diabetes: YesNo
Have you had any previous eye surgery: Cataract SurgeryGlaucoma SurgeryOtherNo
If yes to above, please specify which eye(s) (Right / Left / Both):
Do you suffer from macular degeneration: YesNo
When was the last time you visited an eye doctor for an eye exam:
Do you feel you see well:
Are you having any eye problems at the moment? If yes, please give a brief explanation of the eye problem:

* indicates required fields.