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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

"I met with Dr. Avery and she was absolutely stellar. I don't think I've ever gone in and out of an optometry office so quickly. From the minute I stepped foot inside to when I left, I felt the staff's professionalism. 

During my eye exam she was able to answer all of my questions and provide answers for certain conditions and symptoms that previous optometrists were not able to flag. 

Even better, the contact lenses that she fit for me are the most comfortable I've ever worn. 

I highly recommend Eye Carumba Optometry to anyone looking for a great optometrist with a wide range of appointment options."

March 17, 2017
Mike Tsai

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