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

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 Experience

Even small changes in vision or comfort can be helpful to note.

What have you been noticing most lately?

What You Would Like to Improve

This helps us understand what matters most to you.

What would you most like to improve from this visit?

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)

Insurance (If Applicable)

If you plan to use insurance, please provide that information below. We will review benefits when applicable, but recommendations will always be based on what best supports your vision needs.

How would you like to approach your visit?

I plan to use vision insurance
I am open to recommendations based on my needs
Not sure yet

Recommendations during your visit will always be based on what best supports your vision and daily needs.

Medical & Family History

Pressure Birth Contact

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

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Office Hours

Monday – CLOSED

Tuesday – 11AM to 6PM

Wednesday – 11AM to 6PM

Thursday – 11AM to 6PM

Friday – 12PM to 7PM

Saturday – 11AM to 4PM

Sunday – CLOSED

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2026

Sweet View Optical

USE IT OR LOSE IT!

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