Telehealth Visit Request Name* First Last Date of Birth MM slash DD slash YYYY Best Phone Number*Alternate Phone NumberEmail Address (strongly recommended) Are you requesting a Telehealth visit?* Yes No What are your symptoms?How long have you been experiencing symptoms?On a scale from 0-10, what is the severity of your symptoms with 0 being no symptoms and 10 being severe?012345678910Are you experiencing symptoms in one eye or both? Right Eye Left Eye Both