Patient Information Form for Eyes By Dr. B

Use the online form below to fill out your patient information which will be submitted straight to our office, or click the button below to download and print a hard copy of this form. If you choose to print the form, please fill out all sections and bring it to your appointment with you for a faster check-in process.

Patient Information

Name
Address
May we contact you by email and text messaging?

FOR CHILDREN UNDER 18 YEARS OF AGE

Please answer the questions to the best of your knowledge:

Do you wear glasses?
Going to purchase glasses?
Frequently get headaches?
Have you ever had eye surgery?
Are you Diabetic?
Do you wear contact lenses?
Interested in contact lenses?
Do you ever see double?
Eye Injury?
If female, are you pregnant?

Have you or a blood relative ever had any of the following:

Glaucoma?
Macular Degeneration?
Lazy eye/Amblyopia?
Turned/Crossed eye?
Colorblindness?
Diabetes?

Do you use drops or medications for your eyes?
Are you presently taking any medication (any medication at all)?
Are you allergic to any medication (any medication at all)?
Are you having any problems with your eyes at the current time?