Pediatric Contact Lens Information Form
Please provide accurate and complete information to help us manage your child's contact lens care efficiently.
Child’s Full Name
*
First Name
Last Name
Child’s Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Lens Type or Brand
*
Please Select
Soft (Daily Disposable)
Soft (Bi-weekly)
Soft (Monthly)
Rigid Gas Permeable (RGP)
Other
Current Contact Lens Prescription Details
*
Wear Schedule / Usage Frequency
*
Daily
Occasionally (several times a week)
Only for sports or special activities
Other
Known Lens Issues or Discomfort
Dryness
Redness
Blurry vision
Itching
No issues
Other
Preferred Follow-Up Method
*
Phone
Email
In-person appointment
Additional Notes or Concerns
Submit
Should be Empty: