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Laser Vision Correction Cincinnati Ohio

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Eye History Form

Either fill out this online form below, or download and fill out the Eye History Form (PDF), and bring it with you on your next visit with us.

 
 
 
 
Do you wear contact lenses?
 
 
 
 
 
 
Do you have trouble with distance vision?
 
 
 
 
Do you have trouble with near vision?
 
 
 
 
Do you have trouble with
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you ever been treated for any of the following:
 
 
 
 
 
 
 
 
 
 
 
 
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