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About Us
Our Eye Doctors
- The Staff
Myopia Management at Treehouse
Scleral Lenses
Dry Eyes
Eye Care Services
Eyeglasses
- Progressive Lenses for Presbyopia
- Designer Frames
Contact Lenses
- Difficult To Fit Contact Lenses
- Scleral Lenses

Home » Contact Us » Treehouse Eyes co-management form

Treehouse Eyes co-management form

Please click here to schedule a 15 minute zoom meeting to learn about co-management.

Please click here for 6 months follow up visit co-management form

Patient
Date of Birth
MM slash DD slash YYYY
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
- Asian
- Black
- Latino
- Caucasian
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)
MM slash DD slash YYYY
OD: 20/
OS: 20/
Estimated digital device use
Estimated time outdoors
Referring Doctor
Doctor’s email
Will you be co-managing
- Yes
- No

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Patient Information for Myopia Treatment

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River Oaks Family Optometry

690 River Oaks Parkway #20
San Jose, CA 95134

Phone: 408-502-7636 (ROFO)
Fax: 408-502-7635
Email: info@riveroaksfamilyoptometry.com
(Do not send personal health information by email.)

Top Optometrists in San Jose 2015

River Oaks Family Optometry is ranked in the top San Jose, CA Optometry practices
Verified by Opencare.com

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River Oaks Family Optometry
690 River Oaks Parkway #20
San Jose, CA 95134
Phone: 408-502-7636 (ROFO)
https://www.riveroaksfamilyoptometry.com

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