We're Open!

Monday-Friday 9:00 to 6:00
Saturday 10:00 to 4:00
Sunday Closed

Patient Information Form

Please fill-out this Patient & Health History and HIPAA Authorization Form prior to your appointment.

Your Information

First Name*

Middle Initial

Last Name*

Nickname

Age*

Gender*

Type of insurance*

Date of Birth*

Occupation

Street Address*

City*

State*

Zip*

Email Address *

Day Phone*

how should we contact you?*

Email

Phone

Emergency Contact

Name*

Phone*

Relationship*

You and Eye Carumba

I have been*

seen
not seen

at Eye Carumba Optometry before

Where did you hear about us?*

Reason for this visit*

*Required

Social History

Do you participate in any sport, hobby, professional activities that may require special protection or correction (for example: squash / handball, scuba, music, carpentry)?

Do you use tobacco?

What type / Amount / How Long

Do you drink alcohol?

What type / Quantity / Frequency

*Required

Policies

I have read this consent and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and health care operations.

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:

Your Name

Relationship

Source of
authority

*Required

What Our Patients Say

"Dr. Yeh was professional and easy to deal with. He was knowledgeable and spoke to me at length about some of the issues I have with my vision. They were very thorough and noticed something that my last eye doctor didn't see.

I have a VSP plan, and they made the process very easy.

I really appreciated that they just gave me my prescription (over email) and didn't try to upsell me on their frames.

I would definitely recommend. "

We're Open!

Patient Information Form

Your Information

Emergency Contact

You and Eye Carumba

Vision History

Ocular Health

General Health

Personal Health

Women

Medications

Computer Vision Questionnaire

Time Spent (hours per day) on a Computer / Device:

Lighting in work area (please describe)

Social History

Policies

What Our Patients Say

We're Open!

Office Hours

Order Contact Lenses

Get Directions

Request An Appointment

Call Us 415.772.8282

Patient Information Form

Your Information

Emergency Contact

You and Eye Carumba

Vision History

Ocular Health

General Health

Personal Health

Women

Medications

Computer Vision Questionnaire

Time Spent (hours per day) on a Computer / Device:

Lighting in work area (please describe)

Social History

Policies

What Our Patients Say

Get In touch

Office
Hours

Order
Contact Lenses

Get
Directions

Request An
Appointment

Call Us
415.772.8282