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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

It's always a pleasure to go to Eye Carumba. Dr. Torres is just a wonderful human being. He truly cares about his patients, is always very thorough, fun to be with, has the latest technology and his staff are happy and helpful. Been going to him for more than 20 years and plan to stay with Dr. Torres for the foreseeable future.

February 1, 2018
Suzanne S. Customer since 2005

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