Child Intake Form

Child Intake Form

Child Intake Form

Child Intake Form

Child Intake Form

Child Intake Form



May Enclave Vision text you at this number for matters related to your child's appointment?


Squint (other than in very bright light)?

Have one eye that drifts in/out?

Tilt his/her head frequently?

Rub his/her eyes?

Hold objects very close or sit close to the TV?

Complain of headaches frequently?

Tell you that he/she has difficulty seeing?

This is my child’s first exam

Is your child under a physician’s care for any health conditions?

Is your child currently taking any medications?

Does your child have allergies to any medications?

Are there any eye conditions that run in your child’s family (ex: amblyopia, crossed eye, glaucoma, etc.)?

I have read and understand the Notice of Privacy Practices. Please Initial.

Our optometrists perform both routine eye exams for glasses and contacts, as well as medical eye exams, Should your eye exam include additional testing and treatment for a medical eye condition (dry eye, diabetes, ocular allergies, glaucoma, etc.), your medical insurance may be billed. Please let our staff or your optometrist know if you have any questions regarding this policy.

Eye Health Screenings

Clarus digital image of the retina

Our doctors want every patient over the age of 4 to have the Clarus retinal image performed every year. This image will be taken unless a waiver is signed. This technology provides an ultra wide-field view of the retina and important structures of the eye, and eliminates the need for dilation drops in many (not all) cases. Comparing these images on an annual basis allows for early detection of eye disease. The fee for this image is $30 and is not usually covered by insurance.

Please Initial: