Genetic Eye Screening/ OFA Registration
Please fill out the following information as you want it to appear on the OFA form. Submit this form back to the clinic within at least 7 days before your appointment. If we do not receive the form on time, we cannot confirm your appointment and will call to have it rescheduled. For the appointment, it is helpful if you have an assistant with you. Thank you for your cooperation.

You can submit information for up to 10 patients using this form. If you need to submit information for more patients, please fill out an additional form.
Email address *
Name of Registered Owner *
Your answer
Name of Co-owner (if applicable)
Your answer
Phone number *
Your answer
Address (including City, State and Zip Code) *
Your answer
Genetic Eye Screen Appointment Date: *
MM
/
DD
/
YYYY
Scheduled Check-in Time:
This is the time you should check in so that any necessary eye drops can be administered in preparation for the appointment)
Time
:
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