Medical Intake
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Who is the patient?
Patient first name
This field is required.
Patient last name
This field is required.
Date of Birth
This field is required.
Who are you?
Your First Name
Your Last Name
Phone
Email
Reason for Exam
Attach Photos or Files (optional)
You can securely upload any documents or photos you think are helpful.
You may also fax documents to us at 919-924-0275
Last Eye Exam
Doctor/Practice
Glasses?
Past eye surgeries?
Current Medications
Please list all drops, oral medications, topicals, inhalers.
All Medical Diagnoses
Has your child been diagnosed with any medical condition?
Past Surgeries
All past surgeries of any kind, anywhere on the body, with year it was done.
Allergies and reactions
Do you ever notice eye misalignment?
Was the pregnancy full term?
If no, please list number of weeks at birth.
Are all developmental milestones being met?
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