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Assessment Request Form

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Assessment Request Form

Request a Complimentary Eye and Vision Assessment

After you submit this form, a Patient Counselor will contact you to book an appointment for your assessment.

Current Eyeglass or Contact Lense Prescription

If you answer "YES" to any of these questions, please give us DETAILS.

If YES, please list medications currently used: Include ImitreX (migraine), Amiodarone (cardiac anti-arrhythmic), Flomax (urinary flow), and Accutane (aka Epuris for acne). If Accutane used, must be discontinue for at least 6 months.