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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Our state of the art facility is located at 2180 Troop Drive, Sartell. We are conveniently located just off Pine Cone Road. 

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Address:

2180 Troop Drive
Sartell, MN 56377

Phone:

320.258.3915
866.615.6822

Fax:

320.258.3917

Hours:

Monday 9am - 5pm

Tuesday 9am - 5pm

Wednesday 9am - 7pm

Thursday 9am - 7pm

Friday 9am - 5pm

Saturday Once per month

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