Evaluation Request

HOW IT WORKS

1) Vision Symptom Checklist

Start with our online vision symptom checklist below. Here you will answer questions on symptoms or performance limitations. This will help us better understand your concerns and how we can help.

Vision Symptom Checklist

2) Eye Exam Records

While not required, we highly recommend a healthy eye exam from your eye doctor prior to your appointment. If applicable, please have your primary eye doctor fax over your most recent eye exam records.

Records Request Form

3) Appointment Request

Complete the form below and our patient coordinator will contact you to answer your questions and schedule an evaluation. Please note, we are a fee for service office and not provider for any insurance plan.

Your Name

First Name

Last Name

Cell Phone

(###)

###

####

How did you hear about us?

Main Concern

Which best describes your reason for an evaluation

Patient's Name

First Name

Last Name

Date Of Birth

Patient's date of birth

YYYY

Grade:

When was your last eye exam?

Where was your last eye exam?

Who were you referred by?

Symptom checklist vision score:

See the link above for the form.

What are your goals and expectations for pursuing a Binocular Vision Evaluation and possible treatment?

What is the best time to contact you?

Are there any special needs Dr. Toler needs to be aware of?

Evaluation Request

HOW IT WORKS

Hope Vision Development Center