Thank you for choosing Optik PDX and Dr. Ezra Atikune.  Please complete this e-form so we may better understand your eyecare needs.  Privacy of personal information is very important to us.  We will only use the information for the optometric services and products that we provide. 

Patient Information

Do you wear Sunglasses?
Do you have an East/West commute?
Do you have Vision or Medical Insurance? *
Do you participate in a Flex Spending Account(FSA or HSA)?
Do you currently use?

Reason for Visit


Are you experiencing any of the following?

Ocular and Medical History

Macular Degeneration
Lazy Eye
High Blood Pressure
High Cholesterol
Heart Problems
Thank you for taking the time to fill out this form.  We are truly looking forward to seeing you!
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