KinderSee Application

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Please complete this entire form to request an appointment at our KinderSee clinic.

Now accepting patients from Lancaster, Dauphin, and Lebanon Counties.

KinderSee conducts eye exams by under the direction of David Silbert MD FAAP, a pediatric ophthalmologist, who evaluates your child’s eyes for any medical or vision issues. KinderSee also provides glasses or treatment to those students who have vision issues or vision loss. You may also see Hayley Woodall, OD our pediatric optometrist.

The clinic is located at:

KinderSee
825 Fishburn Road, Lower Level
Hershey, PA 17033

Email *

Child's Full Name *

Child's Date of Birth *

YYYY

What school does the child attend? *

Home Address of the child *

Primary Parent or Guardian's Name *

Phone Number of Parent/Guardian *

Is this phone number a cell phone? *

Yes

Required

Email of Parent/Guardian *

Are we able to email you?

Yes

Child's Ethnic Background (Select all the apply) *

African American

White/Non-Hispanic

Asian/Pacific Islander

Hispanic/Latino

Native American

Decline to Specificy

Other

If there someone else who can bring the patient to an appointment? Please list them below with their relation to the patient.

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