Please Answer the Following To The Best of Your Ability:
Do YOU have or are YOU being treated for problems with any of the following:
Please select as many as apply
Select any surgeries/procedures you have had in the past:
Do any of your BLOOD RELATIVES have (or had) any of the following:
Please click if you have had any of the following symptoms over the past three months:
NOTE: This is a secure form and will not be seen by anyone other than The Elgin Eye Clinic.