Patient Request to Release Medical Records

Appointment with: Dr. Carl Garbus Dr. Danielle Benosa

Have you seen another eye doctor since your last office visit? Yes No

Blurred Vision: Distance or Near Yes No

Irritation Yes No

Are you interested in Contacts? Yes No

Glare or Distortion in your vision Yes No

Allergies Yes No

Arthritis Yes No

Headaches Yes No

Diabetes Yes No

Disorientation / Dizziness Yes No

High Blood Pressure Yes No

Stroke Yes No

Traumic Brain Injury / Concussion Yes No

Thyroid Disease Yes NO

Please let us know if you have/had any of the following symptoms within the last two weeks COVID 19 - Positive COVID 19 - Negative Self Quarantine - YES Self Quarantine - NO Cough - YES Cough - NO Shortness of breath/difficulty breathing - YES Shortness of breath/difficulty breathing - NO Fever - YES Fever - NO Chills - YES Chills - NO Muscle pain - YES Muscle pain - NO Sore throat - YES Sore throat - NO New loss of taste or smell - YES New loss of taste or smell - NO

24 Hour Cancellation Policy I have read, understand, and agree to abide by the policy above.