Virtual Care - OnSight

Do you have a computer/laptop with a webcam?
- Yes
- No
Do you have a space to setup 10 feet away from your computer screen?
- Yes
- No
If you wear glasses or contacts, do you have a copy of your most recent prescription?
- Yes
- No
If not, please contact your eye care provider before proceeding.
Upload your prescription(s) here (if you wear contacts, a photo of the box(es) is acceptable)
Drop files here or

Accepted file types: jpg, png, pdf.
If you don't have it handy, no worries! You will need to email a copy within 24 hours to virtual@onsighteyes.com.

How long has it been since your last eye exam?*
- Less than 1 year
- 1-2 years
- 2-3 years
- Over 3 years
What other issues or problems do you have with your eyes or health? Be specific. Also, please list medications and supplements you are currently taking.

A few last boring questions...
Your Date of Birth (MM/DD/YYYY)*
Date Format: MM slash DD slash YYYY
Your Phone Number*
Preferred appointment times*
Please list a few preferred dates, times, and your current time zone. We will do our best to accommodate your schedule.
Address
City State
I understand that a telehealth evaluation is not a substitute for a full comprehensive eye exam. I also understand that a brief video of my eyes may be taken for diagnostic purposes.*
- Yes, I agree.
This does not replace a full comprehensive eye exam. We recommend that you are seen by an eye doctor every 1-2 years. Furthermore, we may take a 10-15 second video of your eye movements, as requested by our optometrist.
You authorize us to share information to your insurance or benefit plan in order to process and pay your claim.*
- Yes, I agree.
Comments
This field is for validation purposes and should be left unchanged.

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