Kaysprings Eye Clinic

Name *

Email address *

Phone number *

Preferred appointment date and time *

Do you have any existing eye conditions? *

Please select at least one option.

Myopia (Nearsightedness)

Hyperopia (Farsightedness)

Astigmatism

Presbyopia (Age-related vision change)

Glaucoma

Cataracts

Diabetic Retinopathy

None of the above

Have you had any eye surgeries in the past? *

Do you currently wear glasses or contact lenses? *

What type of vision correction are you interested in? *

Please select at least one option.

Glasses

Contact lenses

Vision therapy

None of the above

Do you have any allergies, particularly to medications or materials? *

Please select at least one option.

No

Yes (Mention)

*

How did you hear about kaysprings eye clinic? *

Which service or services are you interested in? *

Please select at least one option.

Comprehensive Eye Examination

Optimal vision Correction

Geriatric Eye Care

Pediatric Vision Care

Optimal Vision Therapy

Contact Lens Fitting

Glaucoma Management

Low Vision Rehabilitation

Emergency Eye Care

Additional questions or comments

Please confirm that you are not a robot.

KAYSPRINGS EYE CLINIC