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Patient Intake Form

  • Medical Conditions:

    Check & List
  • Ocular Conditions:

    Check & List
  • Add a new row
  • Add a new row
  • Add a new row
  • Add a new row
  • ***Dilation or Optos is required for a full health examination. Dilation side effects include light sensitivity and blurred vision for up to 6 hours. Dilation also extends your appointment 20-30 minutes. Optos is an ultra-wide field retinal image with no side effects and has a $43.00 Copay. Any further questions you can discuss with your technician during your exam.