SO Red Eye Form

Date

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Please enter a valid phone number.

Which eye is affected? *

Right Left Both

If both eyes affected, which was affected first?

Right Left

How long has the redness been present?

Describe in time (hours, days) since you first noticed the redness.

Are you experiencing any light sensitivity? *

Yes No

Is your vision blurry? *

Yes No

Is there discharge from the eye? *

Yes No

If yes, please indicate quality of discharge.

Watery Mucous Purulent

Please indicate colour of discharge if applicable:

Any recent illness (i.e. cold, fever, flu)? *

Yes No

Are your eyes experiencing any itchiness? *

Yes No

Are your eyes experiencing any pain? *

Yes No

Do you wear contact lenses? *

Yes No

If yes, when was the last time you wore contact lenses? blanks

Please attach images of the affected eye(s).

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