Your Name (Required)
Mr Mrs Miss Ms
Where do we call you?
When should we call you?
Email Address (Required)
Date of Birth (MM-DD-YY)
Do you currently wear glasses?
ConstantlyWhen neededI do not wear glasses
Do you currently wear contact lenses?
Do you wear sunglasses?
ConstantlyWhen neededI do not wear sunglasses
Amount of computer use per day in hours
Amount of smart phone or tablet use per day in hours
Your Medical History
High blood pressure Diabetes Heart disease Thyroid disorder Lazy/crossed eye Eye injury/infection Glaucoma
Other medical history
Your Family History
Glaucoma Cataracts Lazy/crossed eye
Other family history
Current medication being taken (Including over the counter)
Blood pressure Heart Eye drops Diabetic
Third Party Insurance
Posted on June 3, 2018
Posted on November 12, 2015
Dr. David Oliphant’s Complete Eye & Vision Care Clinic