Name: Cohen Eye Institute
Rating: 4.8

Age*

Under 21

21-30

31-40

41-50

50+

If you have your last glasses Rx please input

Correction currently used (glasses, contacts, bifocal/ progressive)*

Glasses for distance

Contacts

Glasses for near

Bifocals/ progressive

Do you have any eye diseases*

Cataracts

Keratoconus

Macular degeneration

Glaucoma

None

Other

Have you ever been told you have thin corneas?*

Yes

No

Unsure

Do you feel like your eyes are dry, or are you currently being treated for dry eye?*

Yes

No

Unsure

Have you had any previous eye surgeries?*

Lasik

PRK

CXL ( corneal cross linking)

Cataract surgery

Corneal transplant

Other surgery

No surgeries

Do you have any medical conditions?*

Diabetes

Hypertension

Rheumatoid Arthritis

Lupus

Other condition

No conditions

Are you currently pregnant?*

Yes

No

Not applicable

Are you taking steroids of any other immunosuppressant medications?*

Yes

No

Unsure

Full Name* This field is required.

Phone* This field is required.

Email* This field is required.

Date of Birth

Reason for Visit* This field is required.

Choose Location* This field is required.

Message

This field is required.

By completing this form, you are giving us permission to follow-up by phone, email or text.

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