Lifetime EyeCare Patient Form

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Lifetime EyeCare Patient Form

Telehealth Patient Form

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* Indicates required question

Patient First and Last Name: *

Your answer

Best number to contact you: *

Your answer

Email address we can send the video link to: *

Your answer

Patient DOB: *

Your answer

Do you have medical insurance? *

Yes

No

If you do have medical insurance, please provide the following below: Member ID# and Policy Holder Name

Your answer

Brief description of problem: *

Your answer

Eye(s) affected: *

Right

Left

Both

Submit

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