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Dr. Robert F. Collins, Optometrist
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Eye Exam

For an effective eye examination, Dr. Robert F. Collins and associates need to know as much as possible about you. Filling this form out will help us save you time during your office visit.

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

Describe any vision problems you are experiencing.

Loss of vision
Rubbing eyes excessively
Blinking more than usual
Squinting
Crossed or misaligned eyes
Bulging of one or both eyes
Recurring eye infections
Red-rimmed, encrusted or swollen eyelids
Inflamed or watery eyes
Other

Describe any recent eye injuries or surgery.
 The date, the name of the hospital, the doctor and the procedure that was performed.


Describe any other health problems.
Allergies, Chronic health problems, Operations, Other
The material provided on Dr. Robert Collins website is for informational purposes only.
Have your eyes examined regularly and always follow your eye care professional's instructions for the proper use and care of your contacts.
If you experience any pain or discomfort from your contacts, discontinue use immediately and consult your eye care professional.