New Patient Intake Form

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Welcome to our office!

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blue light or UV?
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starting at infancy!

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602-547-3255
patientcare@accenteyes.com

16020 North 35th Avenue
Suite 2
Phoenix, AZ 85053

OUR OFFICE HOURS

MON - THUR - 9:00AM - 6:00PM
TUE - 9:00AM - 6:30PM
FRI - 8:00AM - 2:30PM

Welcome to our New Patient Intake Form Step 2, please complete the form. Check everything and make sure you have filled out the required fields before going to the final step.

MEDICAL HISTORY (needs to be completed for the examination)

List any current medications and the reasons for taking them.

Do you presently wear contacts? YesNo

Do you suffer from any of the following

with glassescontacts if wornwithout correction

(Dashboard/ Computer)
Distance Vision Blurry	YesNo
Middle Distance Blur	YesNo
Near Vision Blur	YesNo
Burning Sensation	YesNo

Dilated at that exam? YesNo

ExcellentGoodFairPoor

Do you or any BLOOD relatives currently suffer from or have a history of:

Significant weight loss/gain/fatigue

[multistep "2-3-https://accenteyes.com/new-patient-intake-form-step-3/"]
[previous]

Dear Dr. Gong,

"I wanted to thank you for all of your help with my vision correction over the last few months.

Coming to your office was a wonderful experience after my retinal surgery! Given the complications after the surgery, I am grateful for you giving me extra time to help me regain my vision.

During my first visit, your staff welcomed me into the office and used multiple diagnostic modalities to identify the reasons for my vision difficulties. I was amazed at the time that you spent personally with me, asking questions, performing tests and reassuring me that we would find the answer. My experience with you and your staff was so different from my previous experiences that I have referred several of my fellow physicians to you for difficult vision correction. I also would like to commend you on creating an environment where patients are seen quickly yet feel that you and your staff really care about their health.

Thank you so much for your care.

Respectfully,

Dr. William Resnick

Prescott Emergency Medicine

Referred by USC Ophthalmology

See More Testimonials...

CHECK TO SEE IF WE ACCEPT YOUR INSURANCE?

Do you smoke?	YesNo
If yes, how often?	DailyOccasionally
If no, have you ever smoked?	YesNo

Do you drink alcohol?	YesNo
If yes, how often?	DailyOccasionally

Do you use recreational drugs?	YesNo
If yes, how often?	DailyOccasionally

Double Vision	YesNo
Itchy Eyes	YesNo
Pain In or Around Eyes	YesNo
Eye Strain / Fatigue	YesNo
Seeing Spots or Lines	YesNo

Seeing Flashes	YesNo
Dry/Scratchy/Watery Eyes	YesNo
Problems with Focusing	YesNo
Headaches	YesNo
Glare	YesNo

High Blood Pressure	YesNo
Color Blindness	YesNo
Cataracts	YesNo
Diabetes	YesNo
Glaucoma	YesNo
Heart Disease	YesNo

Allergies/Sinus	YesNo
Amblyopia (lazy eye)	YesNo
Macular Degeneration	YesNo
Retinal Detachment	YesNo
Eye Injury	YesNo
Keratoconus	YesNo
Endocrine	YesNo

Arthritis	YesNo
Gastrointestinal	YesNo
Respiratory	YesNo
Kidney/Bladder	YesNo
Blood/Bleeding	YesNo
Skin Disease (e.g. eczema)	YesNo
Mental	YesNo

602-547-3255 patientcare@accenteyes.com

Welcome to our New Patient Intake Form Step 2, please complete the form. Check everything and make sure you have filled out the required fields before going to the final step.

**MEDICAL HISTORY** (needs to be completed for the examination)

Do you or any BLOOD relatives currently suffer from or have a history of:

Significant weight loss/gain/fatigue

602-547-3255
patientcare@accenteyes.com

MEDICAL HISTORY (needs to be completed for the examination)