Address

Please list/describe any surgeries you have had in the past 12 months:

Please list any eye infections or injuries you have had in the past 12 months that were not treated at Enclave Vision.

For female patients- please tell us if you are:

Have you noticed any of the following:*

Cosmetic Concerns

Do you have any cosmetic concerns?

CLICK BOXES for the following:

Are you currently taking any prescribed OR over-the-counter medications (including eye drops)?

Please list any medication allergies:

Eye Health Screenings

Clarus digital image of the retina

Our doctors would like all patients over 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.

OCT (Ocular Coherence Tomography)

An OCT screening can detect the earliest signs of certain eye diseases such as glaucoma and macular degeneration. Our doctors recommend that all patients over the age of 40 have a baseline screening performed and also recommend a screening for any patient over the age of 30 who has a family history of glaucoma or macular degeneration.

I would like:

Please provide your initials to acknowledge the information and/or consent for eye health screenings:*

Contact Lens Examination

Are you interested in a contact lens prescription?*