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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

Randomly selected Eye Carumba years ago when I moved into the city (it was close and had good reviews). Since then I have moved several times but keep coming back; excellent service, no pressure, easy appts and genuinely nice folks. I really dont know what else you could ask for from an Optometrist!

October 1, 2017
Aaron Milleson

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