Digital Eye Health Consult Form

Name*

First Last

Phone Number*

Email Address*

Please select an option below.*

New Patient - Never Been at This Office
Established Patient

Gender*

Date of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?*

What symptoms are you experiencing?*

Please click on the field and select all that apply.

On a scale of 1-10, what is your discomfort level? 1 is none, 10 is extremely severe.*

On a scale of 1-10, how badly do you want a solution for your symptoms? 1 is just curious to learn more and 10 is whatever it takes.*

Contacts or Glasses Wearer

Do you currently wear contact lenses?*

Yes
No

Do you currently wear glasses?*

Yes
No

Appointment Time Options

Time Options

What is your preferred time range for an appointment?

Morning Times between 9 am to 12 noon
Midday Hours between 11 am to 2 pm
Afternoon between 2 pm to 5 pm

First Choice*

Second Choice*

Third Choice*

Consent*

I agree to the privacy policy.

I consent that the Company can provide their services and communicate with me via mobile phone, messages, e-mail, and any kind of online communications, provided that these communications comply with privacy regulations.

Appointment Reminders, Reschedules, and Cancellations

I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out to me for the purpose of "confirm", "reschedule" or "cancel".

Telemedicine Appointments

For telemedicine, I understand the appointments will be held via electronic environments.

Contact Information Change

I accept that I am responsible for notifying the Company when my contact information change.

Consent Cancellations

I know that I can revoke this consent at any time by contacting the Company.

I consent to the use of mobile phone communications.

I consent to the use of texting (messages) communications.

I consent to receive electronic notifications for confirming, rescheduling, or canceling my appointments.

I sign this consent form on the behalf of

Myself/My family/Someone as a legal guardian

Digital Eye Health Consult Request

Contacts or Glasses Wearer

Appointment Time Options

Time Options

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