Skip to main content

COVID-19: We have returned to our regular hours.

Is your child distance learning?

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