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Just North of Horsetooth on Shields St. in Fort Collins, CO

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970-276-6060
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Home » SPEED Questionnaire

SPEED Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Report the FREQUENCY of any dry eye symptoms you are experiencing.
  • Report the SEVERITY of any dry eye symptoms you are experiencing using the grid below

  • Digital Retinal Imaging and Computerized Visual Field Consent Form

  • Our state-of-the-art diagnostic tools are considered to be "elective" to a comprehensive eye exam, and therefore are not covered by your insurance and a nominal fee of $36 will be added to your charges.
  • Date Format: MM slash DD slash YYYY