Intake form

Welcome, we are excited to take care of your eye care needs. Due to the COVID outbreak, we have implemented several safety precautions to help keep you safe. At this time, we request that only the patient attend their appointment or one parent/guardian accompany one minor child. In order to limit a patient’s time in the office, we would like to ask you several intake questions ahead of time to better serve your needs. Please answer the following medical questions prior to your appointment.

1. What brings you into the office (ie blurred vision at distance/near, need new glasses, out of contacts, etc)?
2. Have you had any eye surgeries? If so, what surgeries and when? 
3. Have you been diagnosed with any eye diseases? If so, what diseases? 
4. What medical conditions have you been diagnosed with? 
5. What current medications and eye medications are you taking?
6. Is there any additional information you would like us to know in order to help you with your visual needs?
7. Have you had symptoms or been exposed to COVID-19?

You may respond by replying to email westglen@wgeyecare.com, fax your responses to 913-962-2013 or phone in your responses prior to your appointment to 913-962-2010.

 WE REQUEST THAT YOU WEAR A MASK TO YOUR APPOINTMENT