• Patient Intake Form

    Due to the COVID-19 pandemic, we recommend that our patients complete this form prior to their appointment to reduce the amount of time spent in our office for their own health and safety and for our staff. If you are not comfortable filling out this form online, please call our office at (808) 674-2273 and a member of our staff will do a phone work-up instead. Mahalo for your cooperation.
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  • Please Answer These Questions Regarding Your Vision and Eye Health






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  • Please Answer These Questions Regarding Cataracts


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  • Please Answer These Questions Regarding Glaucoma




  • Please Answer These Questions Regarding Surgery Post-Op

    for surgeries done at the Eye Surgery Center of Hawaii
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  • Please Answer These Questions Regarding Sudden Blurry Vision or Loss of Vision




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  • Please Answer These Questions Regarding Allergies (Redness, Itching, Tearing, Discharge)






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  • Please Answer These Questions Regarding Dryness







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  • Please Answer These Questions Regarding Foreign Body

    (something stuck in eye or sensation of something in eye)



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  • Please Answer These Questions Regarding Headaches






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  • Please Answer These Questions Regarding Eye Pain




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  • Please Answer These Questions Regarding Sensitivity to Light




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  • Please Answer These Questions Regarding Flashes and Floaters




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  • Please Answer These Questions Regarding Spasm





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  • Please Answer These Questions Regarding Growth






  • Please Answer These Questions Regarding Droopy Eyelid(s)


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  • Please Answer These Questions Regarding Trauma/Eye Injury




  •    
  • Please Answer These Questions Regarding Your Eye Problem




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  • Review of Systems and Social History

  • COVID-19 Questionnaire

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