Complete Our Eye Exam Pre-Appointment Form

This form helps our doctors prepare for your exam by letting them know about any potential issues you may be having with your eyes. Complete it at your own convenience prior to your appointment so our team can help you achieve healthier eyes and clearer vision.

Text Today! (928) 264-8951

Complete Eye Exam Pre-Appointment

"*" indicates required fields

Complete these 2 easy steps for a smooth check-in for your appointment.

Step 1: Fill out and submit this form online:

Step 2: Download and fill out the "Acknowledgement of Notice of Privacy Practices" form, and bring it with you to your appointment

Do You ever experience any of these eye-related symptoms?

Dryness, Burning, Tearing, Redness, Itching, Fatique, Scratchy or Gritty Sensation.

My eyes are Dry, Gritty and Scratchy*
My eyes are sore and irritated*
My eyes burn or water*
I experience eye fatigue*
My eyes are red*

If YES please answer the following five questions and rate your symptoms based on a scale of 0-4

  • 0 - Never
  • 1 - Seasonally
  • 2 - Sometimes
  • 3 - Often
  • 4 - Constantly
Are you interested in contact lenses?*
Do you currently wear contact lenses?*
Are they comfortable?*
What do you wish was better about your contact lenses?*

Download and fill out the “Acknowledgement of Notice of Privacy Practices” form, and bring it with you to your appointment!

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What Our
Patients Are Saying

"As a new patient, I was very pleased with my experience. Everyone I interacted with was friendly, helpful, and professional. They were efficient and on time. The office was clean and cool. The doctor provided a very thorough eye exam and took the time to answer all my questions. They were even able to resolve an insurance issue for me in a timely manner. I would highly recommend them!"


What Our
Patients Are Saying

"I had one of THE MOST thorough eye exams ever! Everyone was so kind & professional. I have to say that my eyes are very complicated. Dr. was very helpful listened to my needs and did the best she could for my situation!! I’ll be back after a couple of needed eye surgeries!"


What Our
Patients Are Saying

"We've had a great experience with Lake Havasu Family Eyecare. It's nice to go to a doctor's appointment and not feel like you are just a number. These folks really take the time to make sure you are getting what you want and that you are happy with your glasses/contacts. They also have a nice selection of frames. I have found this to not be the case at some other offices throughout my 40 years of wearing glasses."


What Our
Patients Are Saying

"My eye was infected and they were so kind to get me in after the weekend. They were very caring and kind. They attended my eye very caringly."