Dry Eye Patient Intake Form


Sides: Single Sided
Single Sided
Double Sided
PDF Only
Amount: 250
1 Branded PDF

Comprehensive patient intake form specifically structured for a dry eye evaluation visit. Designed to be handed to patients following their full exam as they schedule their dry eye follow up appointment. 

Includes everything from symptoms (with built-in SPEED questionnaire), habits, make-up use, contact lens history, relevant medical history, work and home environmental factors, success of previously attempted treatments, and patient's goals for treatment. 

If you're trying to build up your specialty dry eye clinic, this form provides a solid framework for gathering patient history to help determine commonly overlooked causes and establish a treatment plan that will accomplish your patient's goals AND prevent disease progression. 

Size: US Letter Portrait (8.5 x 11 in), printed on 24 lb laser paper (90 gsm)

Listing price covers cost for printed documents, shipping, and customization (adding office logo and necessary information and altering colors to match branding).

Want to save some trees? Check out the fillable PDF version of this intake form instead! 

Special Notes: Please attach logo prior to purchasing!