Paperless Check-in

Doctors
Patients
Exam
procedures
cost
Resources

Doctors
Patients
Exam
procedures
cost
Resources

NO CLIPBOARD, NO WAITING ROOM.

We are excited to help you explore your options for Modern Vision Correction! The 10 questions below take about 1 minute to complete, and will give our doctors and team here additional knowledge about you so they can be better help you explore your vision correction options during your visit with us.

Name *

First

Last

Mobile Phone Number *

Preferred Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

You must be at least 18 to have a vision correction procedure.

A few short questions to LEARN ABOUT YOU:

Who is your employer?

Do you wear contact lenses?

No
Yes, soft/disposable contacts (Most people)
Yes, hard/rigid gas permeable contacts

Are you ALLERGIC to any medications or materials? If YES, please list:

No Known Drug Allergies
Yes

Please List The Items You Are Allergic To:

List any MEDICATIONS you currently take:

Medical / Eye history (Check ANY that are KNOWN)

NONE
Eye trauma or infection
Auto immune disease
Cataracts (Cloudy lens)
Diabetes
Retina problems / Glaucoma
Pregnant or Nursing
Prism in glasses / "Crossed" eyes
Ocular herpes Infection
History of "keloid" scarring
HIV or Infectious hepatitis
Keratoconus

Have you ever been told you're NOT a candidate for a vision correction procedure? *

If YES, what was the reason?

Have you ever had any type of PREVIOUS eye surgery? *

If YES, what type of surgery did you have?

Is there a particular type of vision correction procedure you're interested in having?

What are you looking forward to the MOST after having Modern Vision Correction?