Step
1
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10
10%
How did you hear about us?
Google
Google Maps
Social Media
Friend/Family/Word of Mouth
Eye Doctor Referral
Radio Ad
Billboard
TV Ad
Other
Who is your eye doctor that referred you?
Please describe
Name
(Required)
First
Last
Date of Birth
(Required)
Month
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1920
Gender
(Required)
Male
Female
Other
Prefer not to say
Are you currently pregnant or breastfeeding?
Yes
No
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Photo of ID
Max. file size: 50 MB.
Because we are a medical office, you will need to bring a copy of your ID with you to your first visit. We will make a copy of it when you arrive, but if you would like to scan or take a picture and upload it here yourself, it will save time at your visit. If you have any questions or concerns regarding this, please don’t hesitate to call us.
Medical History
Do you have any of the following conditions?
Diabetes
Autoimmune conditions
Glaucoma
Cataract
Macular degeneration
Dry eye syndrome
High blood pressure
Heart disease
Stroke
Anxiety
Depression
Other
Medical History Continued
Please list any other medical conditions that you have.
Medications
Please list any medications you are currently taking.
Have you ever had LASIK before?
Yes
No
Eye History
Have you ever had any eye injuries, eye surgeries, or been diagnosed with any eye conditions or diseases (other than needing glasses and contacts)?
Yes
No
Eye history continued
Please describe your previous eye injuries, eye surgeries and/or eye conditions.
Have you ever had a consultation for LASIK or vision correction before?
Yes
No
Where did you have your previous consultation(s)?
Ocular prosthetic devices
Which of the following do you wear?
Glasses
Contact lenses
For my glasses, I wear…
Single vision glasses for nearsightedness
Single vision glasses for farsightedness
Reading glasses only
Bifocals/progressive lenses
I’m not sure
My contacts are…
Soft, spherical contacts without astigmatism
Soft contacts with astigmatism
Hard contact lenses
Contact Lens Cessation
Wearing contact lenses can warp the shape of your eye. In order to get accurate scans and measurements of your eye for you Advance Ocular Analysis, we request that you be out of soft contact lenses for at least a week prior to your visit. If this is not possible or you have any concerns about it, please call or text us at 971-362-2020.
I understand
Contact Lens Cessation
Wearing contact lenses can warp the shape of your eye, and hard contact lenses have a much greater effect than soft contact lenses. We ask that you be out of your hard contact lenses for at least a week prior to your AOA. However, please be aware that to get the most accurate measurements it is often recommended to be out of hard contact lenses one month for every decade that you have been wearing them. If this is not possible or you have any concerns about it, please call or text us at 971-362-2020.
I understand
Right eye glasses/contact prescription
If you know it, please enter your glasses prescription
Left eye glasses/contact prescription
If you know it, please enter your glasses prescription
Contact lens prescription
If you have it, please upload a photo of your contact lens box or blister pack that shows your prescription.
Max. file size: 50 MB.
