Tell Us About Your Emergency

Complete this form so our emergency receptionist can evaluate your situation and connect you with the on-call doctor. You will be contacted within 10 minutes of submitting.

How It Works

Submit this form with a $10 fee. This fee goes toward your visit charge if you proceed with a telehealth or in-person visit. It is not for a diagnosis.
Our emergency receptionist calls you within 10 minutes. They will reach out to the phone number you provide below.
The receptionist reviews your form with the on-call doctor and schedules either a telehealth visit ($150) or an in-person emergency visit, depending on severity.
Certain emergencies may require an in-person visit — this will be determined once your paperwork is reviewed. In-person visit pricing will be communicated over the phone.

Fee Credit Policy

The $10 submission fee is credited toward your visit charge (telehealth or in-person). If you decline both visit options, the fee is non-refundable.

We Call You

Our emergency receptionist will call you within 10 minutes. We will try 2 times. If you don't answer, no refund is issued.

Not a Diagnosis

This form is for contacting our emergency desk. A doctor determines next steps after reviewing your submission.

Patient Information

First Name

Last Name

Best Phone Number to Reach You

This is the number our on-call staff will call. Make sure you can answer.

Best Time to Call / Notes

Date of Birth

Primary Complaint

What is your main eye problem or symptom?

FOLDARQ Assessment

Please answer each question about your symptoms in detail. This helps the doctor evaluate your condition.

Acknowledgements & Consent

FEE POLICY: I understand the $10 submission fee will be credited toward my visit charge if I proceed with a telehealth or in-person visit. If I decide against both visit options, the $10 fee is non-refundable. This fee is for submitting this form and having an on-call staff member contact me — it does not constitute a medical consultation or diagnosis.

MISSED CALLS: I understand that the on-call staff will attempt to call me up to 2 times. If I do not answer either call, no refund will be issued and I will need to resubmit the form with a new $10 fee.

I understand that submitting this questionnaire costs $10, which will be credited toward my visit charge if I proceed with treatment. If I decline both telehealth and in-person visit options, the fee is non-refundable. If a telehealth visit is needed, the cost is $150 (minus the $10 credit). If an in-person emergency visit is required, pricing will be communicated over the phone. This questionnaire does not constitute a medical diagnosis. I agree to the Terms & Conditions.

By submitting, you agree to all terms above. Payment processing will be enabled shortly.