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  • 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

Emergency Contact

You and Eye Carumba

at Eye Carumba Optometry before

*Required

Vision History

Ocular Health

Please indicate any of the following that apply to you or members of your family:

General Health

Please indicate any of the following that apply to you or members of your family:

Personal Health

Women

Medications

Please indicate all medications you are currently taking:

*Required

Computer Vision Questionnaire

If you work with computers, please complete this section. If you do not, you may skip to the next section.

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


Lighting in work area (please describe)


Social History

*Required

Policies

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:

*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.  "

July 13, 2016
David F.

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