Low Vision Online Questionnaire

Please carefully complete our questionnaire. This form does not need to be printed, once submitted, we should receive it on our end. The information supplied will allow for more efficient use of time and will permit us to make a complete optometric evaluation of your visual system related to your specific needs. 

48 Hour Cancellation Policy

We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill other patient’s scheduling needs and keeps the clinic operating at is most efficient level. Due to our 60-minute exams missed appointments are a significant inconvenience to your doctor, the clinic and other patients.

This policy is in place out of respect for our doctors and our clients. Cancellations with less than 48 hours notice are difficult to fill. By giving last minute notice or no notice at all, you prevent someone else from being able to schedule into that time slot and leave a 60-minute hole in the doctor’s schedule.

  • Please provide our office with 48-hour notice to change or cancel an appointment. Patients who do not attend a scheduled appointment or do not provide 48-hour notice to change a scheduled appointment will be responsible for a $200.00 service chargeThis charge cannot be billed to insurance and must be paid before scheduling your next appointment.
  • We reserve your one-hour appointment time just for you. We do not double-book our patients so that we may provide optimum treatment outcomes for all our patients. 48-hour notice allows us to offer that time to a wait-listed patient.

NOTE: You will never be charged for a cancellation if it is made more than 48 hours in advance of your scheduled appointment time.

Thank you for providing our office and our patients with this courtesy.

Sincerely,

Drs. Garbus & Benosa, and the Family Vision Care Staff

Please check one of the following:

Appointment with:
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General Information

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Gender
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Patient History

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Vision History

Loss of Vision
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Blurred Vision
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Distorted Vision/Halos
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Loss of Side Vision
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Dryness
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Mucous Discharge
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Redness
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Sandy or Gritty Feeling
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Itching
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Burning
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Foreign Body Sensation
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Excess Tearing/Watering
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Glare/Light Sensitivity
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Eye Pain or Soreness
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Chronic Infection of Eye or Lid
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Sties or Chalazion
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Flashes/Floaters in Vision
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Tired Eyes
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Which was prescribed last eye exam?
Would you like information regarding refractive surgery (Lasik)?

Contact Lens Policy: If you are requesting a contact lens prescription, our office provides a full service program – evaluation, fitting, and follow-up. Our office does not release the contact lens prescription until you have been successfully evaluated and fitted.

Review of Systems

Do you use tobacco products?
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Do you consume alcohol?
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Do you currently, or have you ever had any problems in the following areas? If you do, please explain.

Integumentary (Skin)

Neurological

Headaches
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Migraines
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Seizures
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Hay Fever
Sinus Congestion
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Runny Nose
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Post-Nasal Drip
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Chronic Cough
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Dry Throat/Mouth
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Cold Sores
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Respiratory

Asthma
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Chronic Bronchitis
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Emphysema
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Tuberculosis
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Vascular

Diabetes
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Heart Pain
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High Blood Pressure
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Vascular Disease
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Genitourinary

Genitals
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Kidney
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Bladder
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Venereal Disease
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Syphilis
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Gonorrhea
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Bones, Joints, and Muscles

Rheumatoid Arthritis
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Muscle Pain
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Joint Pain
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Family History

If anyone has any of the following conditions, please indicate who. If not applicable, please leave it blank.

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Low Vision Supplement

Have you had a low vision examination before?
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Do you know the cause of your vision loss?
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Has your vision changed significantly in the last three months?
Have you had any eye surgeries?
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Which eye was operated on?
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Does sunlight bother you?
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Please do not submit any Protected Health Information (PHI).

Hours of Operation

Monday  

9:00 am - 6:00 pm

Tuesday  

9:00 am - 6:00 pm

Wednesday  

9:00 am - 6:00 pm

Thursday  

9:00 am - 6:00 pm

Friday  

9:00 am - 6:00 pm

Saturday  

Closed

Sunday  

Closed

Location

Find Us On The Map!