Patient

Date of Birth

Gender

M
F

Parent’s Name

First Last

Email

Phone

Parent’s preferred contact method

email
phone

The patient’s parent has had their questions answered regarding the consequences of treating versus not treating their child’s myopia (for example, possible eye health implications of increasing myopia).

Yes
No

Ethnicity

Patient has been myopic for approximately (years)

Parents myopic

Yes
No

Who

Mother
Father

Siblings myopic

Yes
No

How many myopic siblings

VA sc:

OD: 20/

OS: 20/

Current Subj Rx:

OD:20/

OS:20/

Previous Rx: (date)

OD: 20/

OS: 20/

Estimated digital device use

Estimated time outdoors

Referring Doctor

Doctor’s email

Will you be co-managing

Yes
No

Treehouse Eyes co-management form

Follow Us

Locate Us

River Oaks Family Optometry