Clara Optical

Patient intake

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1 Details
2 Consent
3 Health
4 Insurance

Step 1 of 3

Confirm your details

First name Last name Phone Email

Date of birth *

Month Day Year

Zipcode Language Gender

Step 2 of 3

Review and sign consent

Consent form

Open the consent form before signing below.

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I have reviewed the consent form and agree to sign electronically.

Signature

Step 3 of 3

Health questionnaire

Question

✓

Intake completed

Thank you. You may return the iPad to the staff.

Consent form

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