Child Intake Form

COVID-19 safety agreement

I agree:

How did you hear about our office?

Parents, does your child...

Squint (other than in very bright light)?
Tilt his/her head frequently?
Have very watery eyes?
Complain of headaches frequently?
Have one eye that drifts in/out?
Rub his/her eyes?
Hold objects very close or sit close to the TV?
Tell you that he/she has difficulty seeing?

Our optometrists perform both routine eye exams for glasses and contacts, as well as medical eye exams. Should your exam include additional testing and treatment for a medical eye condition (ex: dry eye, diabetes, ocular allergies, or glaucoma), your medical insurance may be billed. Please let our staff or your optometrist know if you have any questions regarding this policy.

Eye Health Screenings

Clarus digital image of the retina

Our doctors want every patient under the age of 4 to have the Clarus retinal image performed every year. This technology provides an ultra wide-field view of the retina and important structures of the eye, and eliminates the need for dilation drops in many (not all) cases. Comparing these images on an annual basis allows for early detection of eye disease. The fee for this image is $30 and is not usually covered by insurance.

Thanks for submitting!