Health History/DEQ5/MPOD

Ocular History

Review of Symptoms (check all that apply)

During the past month, how often did your eyes feel discomfort?

When your eyes felt discomfort, how intense was this feeling of discomfort at the end of the day, within two hours of going to bed?

During a typical day in the past month, how often did your eyes feel dry?

When your eyes feel dry, how intense was this feeling of dryness at the end of the day, within two hours of going to bed?

During a typical day in the past month, how often did your eyes look or feel excessively watery?

I acknowledge that I am responsible for all charges for services or supplies provided by PineCone Vision Center for myself and/or any family members I am responsible for including minor children. I understand that payment is required at the time service is rendered and that if PineCone Vision Center is a provider for my insurance that they will bill eligible services to my insurance company on my behalf. Therefore, I understand that it is essential that I provide complete and accurate information regarding my insurance company. I authorize medical care and accept financial responsibility for myself and/or any family members I am responsible for including minor children.

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It's time to visit us, schedule now!

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Sartell Location

2180 Troop Drive,

Sartell, MN 56377

Hours:

Monday: 9am-5pm

Tuesday: 9am- 5pm

Wednesday: 9am - 7pm

Thursday: 9am - 7pm

Friday: 9am-5pm

Saturday: By Appointment

Sunday: Closed

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St. Cloud Location

3274 Nottingham Rd,

St Cloud, MN 56301

Hours:

Monday: 9am-5pm

Tuesday: 9am- 5pm

Wednesday: 9am - 5pm

Thursday: 9am - 5pm

Friday: 9am-5pm

Saturday: Closed

Sunday: Closed

Contact Us Today

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Call or Text:

320.258.3915
866.615.6822

Fax: 320.258.3917

Email:

info@pineconevisioncenter.com