EVEA Triage Form

Triage Form

Please provide additional information below to help us provide the best care and determine the urgency of your concerns. After completing, our team will contact you to schedule or collect more detailed information if needed.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date of Birth
Are you a current patient of Eastern Virginia Eye Associates?*

YESNO
Which best describes your condition/concern?*

Eye Irritation or PainPink Eye/Red EyeEye Discharge/Crusting/MatteringWatery EyesBlurry VisionFlashes/FloatersSomething in My EyeDry EyesBump on EyelidEye InjuryOut of Contact LensesOther
Which eye has the condition?*

Right EyeLeft EyeBoth Eyes
How long ago did it start?*

Today1-3 day ago3-7 days agoOver a week ago
Since starting, it has gotten:*

BetterWorseAbout the same
Which best describes your blurry vision?

Out of focus (Distance)Out of focus (Near)Distorted visionDarkening or Dimming of VisionSpots in Vision
Have these changes appeared suddenly or gradually?

SuddenlyGradually
Scale of 1 - 10 How bad is the eye pain / irritation?

1-2 (Not very painful)3-45-6 (Moderately Painful7-89-10 (Very Painful)
Do you have a prescription?

Yes, I have a valid prescription.Yes, but my prescription is expiredNo
Are there any additional details you would like to let us know?
Thank you for providing this important information.

Our doctors and team will review this information and contact you as soon as possible. If this form is received during normal business hours, we will contact you the same day. Our normal business hours are Monday through Friday 8am-5pm EST. If this form is received before or after normal business hours, we will contact you as soon as normal business hours resume. If this is a vision threatening or life threatening emergency, we recommend you seek care immediately at your nearest emergency department.
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Triage Form

Thank you for providing this important information.