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Our Team
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Eye Care Services
Low Vision
Glasses & Contacts
Insurance Info
Our Team
Contact Us
Return Patient Update
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*
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Name
*
Address
*
Preferred Contact Number
*
Preferred Contact Method
*
< select >
Text
Call
Email
Reason For Appointment (check all that apply)
*
Routine Eye Examination
Vision Changes
Ocular Health Concern
Need/Want Glasses Update
Need/Want Sunglass Update
Contact Lens Assessment
Preferred Doctor
*
Dr. John Pond
Dr. Michael Lunardo
no preference/first available
Have you had any flu-like symptoms (fever, chills, etc) within tha past 14 days?
*
Yes - if yes, please phone the office
No
Are you currently COVID +'ve or awaiting COVID test results?
*
Yes - if yes, please contact the office
No
Please let us know of any concerns you would like discussed:
*
Please list your current medications:
*
Digital Device Usage (computer, tablet, phone)
*
>5 hours per day
3-5 hours per day
1-3 hours per day
<1 hour per day
Visual Demand Update (are you doing any new sports, hobbies, activities that requires visual correction? eg. detailed near work, gamer, woodworking, fishing, etc)
Are You Using Private Insurance To Help Pay for The Exam or Eyewear?
*
Yes
No
***if yes, please bring insurance card to appointment and verify eligibilty dates before coming for exam***
Insurance Carrier
If you wish to process your exam or eyewear fees through private health care insurance, please ensure all this information is accurate (names are written as on card) and up to date.
Comments
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