Client Intake Form

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About You

Basic information to prepare your visit

Name

First

Middle

Last

Date of Birth

Click/tap on the year to either scroll or type your answer.

Gender

What pronouns do you use?

This helps us address you correctly during your visit.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Secondary Phone

What Brought You In Today?

Tell us what you have been noticing

Digital & Functional Vision

Difficulty Seeing the Computer or Screens
Eye Strain or Visual Fatigue
N/A

Comfort & Sensitivity

Light Sensitivity
Dry, Irritated, or Watery Eyes
General Discomfort with Vision
N/A

Performance & Safety

Trouble with night driving
Glare or Halos Around Lights
N/A

Neurological / Advanced Symptoms

Headaches
Migraines
Double vision
N/A

Care & Follow-Up

Doctor-Directed Follow-up
Updating Glasses Prescription
Updating Contact Lens Prescription
Interested in Specialty Lenses (migraine, light sensitivity, etc.)
N/A

Other (please specify):

your In Sign

Your Current Eyewear (if applicable)

What you are using now and how it is working

Do you wear glasses and if so, how old are your current pair?

**If yes, please bring your most recent pair of glasses with you to your appointment.

Do you have sunglasses(Polarized or Non-Polarized)?

Yes (Prescription)
Yes (non Prescription)
No

Your Current Contact Lenses (if applicable)

What you are using now and how it is working

Do you wear contact lenses?

Yes
No
Used To

Your Day-to-Day Visual Needs

Work, screens, driving, hobbies, and daily use

What do you do for work?

How many hours per day do you spend on screens?

< 2
2 to 4
4 to 8
8+

List any current sports you play

List any current hobbies you have

Eye & Vision History

Previous care and changes you have noticed

Date of Last Eye Exam

Your best guess will do.

Last Eye Exam Doctor/Office Name

Have you had any changes in your vision, eye comfort, headaches, or light sensitivity since your last exam?

Yes
No
Not sure

Previous Eye Surgery Details, including LASIK (if applicable)

Vision Insurance Benefits & Reimbursement

Sweet View Optical accepts a limited selection of vision benefit plans that align with the personalized care and quality eyewear we provide. If we are not in network with your plan, we offer a concierge Out-of-Network Filing Service. We will help prepare and submit your claim so your insurance provider can reimburse you directly for any eligible benefits. Payment is due at the time of service. Reimbursement amounts and eligibility are determined by your individual plan and are not guaranteed by Sweet View Optical.

I acknowledge the above Vision Insurance statement and that Payment is due at the time of service.

Click Here to Acknowledge

Medical & Family History

Consent, Acknowledgement & Authorizations

A few quick confirmations to help us deliver your care smoothly, protect your privacy, and keep everything properly documented. You can review full details anytime in our Privacy Policy

Health Information Authorization (HIPAA)

By signing above, I authorize the secure sharing of my eye health information between Digital Optometrics and Sweet View Optical for the purpose of my exam, prescriptions, and care coordination. I understand I can revoke this authorization at any time.

Decline to Health Information Authorization (HIPAA)

Decline to Sign Health Information Authorization (HIPAA)

I decline to authorize the sharing of my health information. I understand this may limit the ability to complete my exam or provide certain services.

Prescription Acknowledgment

By signing above, I understand that I will receive a copy of my glasses and/or contact lens prescription at the end of my exam. I may choose to receive it digitally or on paper, and I can request a copy at any time while it is valid.

Decline to Sign Prescription Acknowledgment

Decline to Sign Prescription Acknowledgment

I decline to acknowledge receipt of my prescription. I understand that my prescription will still be provided in accordance with federal regulations.

Social Media Consent- You Look GREAT! Is it okay if we post this?

By signing above, I give permission for Sweet View Optical to use my photos, videos, or testimonials for social media and marketing. I understand this is completely optional and does not affect my care.

Decline to Sign Social Media Consent

Decline to Sign Social Media Consent

I do not give permission for my images, videos, or testimonials to be used for marketing or social media.

Are You Signing/Declining on Behalf of the Client?

Contact Info

245 Peachtree Industrial Blvd Suite 103 Sugar Hill, GA 30518

(678) 253-7975

Take the "Good Enough" Assessment

Take the Migraine Assessment

Book Your Eye Exam

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Come hang out with us.
Style drops, studio moments, and the occasional surprise.

Office Hours

Monday – 11AM to 6PM

Tuesday – 11AM to 6PM

Wednesday – 11AM to 6PM

Thursday – 11AM to 6PM

Friday – 12PM to 7PM

Saturday – 10AM to 6PM

Sunday – 12PM to 6PM

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