Online Forms

Online Forms

Online Forms

At Federal Hill Eye Care, we offer patient forms online so you can complete them on your computer in the convenience of your own home or office. You may email us the completed forms or bring them with you on your next visit.
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For our new patients – in order to save time and be more efficient at your appointment, please:

  • Print out our Patient History Form and sign our Notice of Privacy Practices.

  • Fill out the forms to the best of your knowledge.

  • Bring them with you to your eye exam appointment.

Wellness Form

First Name
Last Name
Phone
Email
Do you have cough?
Do you have a fever now or have you in the past 14-21 days?
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
Are you experiencing shortness of breath or difficulty breathing?
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Have you experienced recent loss of taste or smell?
Are you over the age of 60?
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)?
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