Patient Intake Forms - Dry Eye Master

Laura M. Periman, M.D. is currently accepting new patients and re-establishing previous patients for dry eye evaluations, consultations, and advanced services via telemedicine. You can complete all of your patient intake information here with our easy-to-use tools. Submitting this information in advance will make your appointment more relaxed, efficient, and healing. Please complete all of the patient intake information at least 24 hours prior to your scheduled appointment, including
1. Name & email address
2. Payment & appointment details
3. General information forms (5)
4. Questionnaires (3)
5. Eye image uploads
6. Vision acuity test
If you are looking for a specific form, click the "Forms" tab at the top of the page. We are delighted you are here and look forward to being your partner in restoring your eye health. Get started below!
Name*
First Last
Email*
Payment Information*
I understand
Payment Information

Dr. Periman is not contracted with any medical insurance plans. Consultation fees are due at the time of service. We will provide you with a detailed, itemized receipt of payment including CPT codes that you may submit to your insurance for possible, partial reimbursement of “out of network” benefits to be determined by your insurance.

Did you complete all information in the Patient Demographics form above and press the submit button at the bottom of the form?
- Yes
- No
If you're having trouble, please contact us.

Did you complete all information in the Patient Financial Policy above and press the submit button at the bottom of the form?
- Yes
- No
If you're having trouble, please contact us.

Did you complete all information in the Notice of Privacy Practices form above and press the submit button at the bottom of the form?
- Yes
- No
If you're having trouble, please contact us.

Did you complete all information in the Telehealth Consent Form form above and press the submit button at the bottom of the form?
- Yes
- No
If you're having trouble, please contact us.

Did you complete all information in the Dry Eye Intake Form above and press the submit button at the bottom of the form?
- Yes
- No
If you're having trouble, please contact us.