Retina evaluation intake that flags sudden vision loss up front
Ask about sudden vision-loss symptoms, diagnosed retina conditions like diabetes or hypertension, and how soon the patient wants to be seen, then collect their recent eye exam records or imaging before you ever schedule a slot.
The exact intake your retina evaluation leads complete
This is the real 6-question guided intake for Retina Evaluation — the same flow your customers finish before you ever pick up the phone.
What a qualified retina evaluation lead should tell you
A dilated or imaging-based exam of the retina used to identify damage, disease, or vision-threatening changes, and to determine how urgently the patient needs to be seen.
- Main Reason Retina Evaluation
- Experiencing Sudden Vision Loss,
- Have Diagnosed Condition That
- Have Recent Eye Exam
- Soon Be Seen
- Legally Authorized Make Medical
The questions your team needs answered
Every retina evaluation intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| What is the main reason you need a retina evaluation? | The reason for the visit sets the baseline priority, with injury, new vision changes, and referrals weighted highest as likely active retina issues. |
| Are you currently experiencing sudden vision loss, flashes, or new floaters? | A 'yes' on sudden vision loss, flashes, or new floaters carries the highest weight in the catalog and points to a possible retinal detachment or emergency. |
| Do you have a diagnosed condition that affects the retina, such as diabetes or hypertension? | Confirming a diagnosed condition like diabetes or hypertension identifies patients who need retina evaluation as part of managing a systemic disease. |
| Do you have recent eye exam records or imaging you can share with the provider? | Knowing whether recent records or imaging exist tells the provider if findings can be reviewed ahead of the visit or need to be captured fresh. |
| How soon are you hoping to be seen? | The desired timeframe question, weighted highest for 'as soon as possible', tells staff how quickly to move the patient into an available slot. |
| Are you legally authorized to make medical decisions for the person being evaluated? | Confirming legal authorization to make medical decisions matters when the intake is completed on behalf of a minor or incapacitated patient. |
How Cliont scores retina evaluation leads
Every answer is weighted automatically — no manual review required.
Value signals
- New vision changes or distortion
- Routine monitoring due to diabetes
- Referral from another doctor
- Eye injury or trauma
- General routine eye checkup
- Other reason
See the lead your team receives
Retina Evaluation Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for retina evaluation workflows
| Cliont capability | Retina Evaluation application |
|---|---|
| Conditional urgency routing | A 'yes' on sudden vision loss, flashes, or floaters combined with an 'as soon as possible' timeframe automatically raises the lead above routine-checkup requests. |
| Document collection | When a patient confirms they have recent eye exam records or imaging, the intake prompts them to upload it before the appointment is booked. |
| Consent and authorization checks | The authorization question is used to hold or flag intakes where the person submitting the form cannot legally consent for the patient being evaluated. |
| Condition-based segmentation | Answers about diagnosed diabetes or hypertension let the practice separate disease-monitoring visits from symptom-driven or referral visits at intake. |
Common retina evaluation lead scenarios
Sudden flashes or new floaters
Patient reports sudden vision loss, flashes, or floaters and wants to be seen as soon as possible, the two highest-weighted signals in the catalog, so the intake pushes this straight to the top of the queue.
Diabetic monitoring visit
Patient selects routine monitoring due to diabetes and confirms a diagnosed retina-affecting condition, a lower-urgency but still valuable case the intake can route without treating it as an emergency.
Referral with existing imaging
Another doctor referred the patient and they already have recent eye exam records or imaging, letting the practice review findings before booking rather than starting from scratch.
Trauma or injury case
Patient reports an eye injury alongside sudden vision changes and wants to be seen immediately, combining two high-weight answers that the intake should never let sit in a general queue.
General checkup, no urgency
Patient selects a general routine checkup with no specific timeframe and no sudden symptoms, the lowest-weighted combination in the catalog, so it can be scheduled on normal availability instead of an urgent slot.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More ophthalmology intake templates
Retina Evaluation lead-intake FAQs
How does the intake treat sudden vision loss, flashes, or floaters?
That question carries the highest yes-weight in the catalog, so a 'yes' answer flags the lead as needing prompt attention rather than sitting in a standard queue.
Does the form ask about diabetes or hypertension?
Yes, patients are asked whether they have a diagnosed condition that affects the retina, with a yes, no, or not sure option, so diabetic and hypertensive patients can be identified for retina-specific follow-up.
Can patients submit prior exam records or imaging through the intake?
The intake asks whether the patient has recent eye exam records or imaging to share, so the provider knows up front whether existing scans can be reviewed before the visit.
How does the desired timeframe affect how a lead is prioritized?
Patients who select 'as soon as possible' score highest on that question, while 'no specific timeframe' scores lowest, giving staff a clear signal for how quickly to respond.
Does the intake check who is filling out the form for a patient who can't answer for themselves?
Yes, it asks whether the person completing the intake is legally authorized to make medical decisions for the patient being evaluated, which matters for minors or incapacitated patients.
How is a routine checkup handled differently from a symptom-driven visit?
A general routine checkup scores lower than new vision changes, referrals, or injury, so those requests can be scheduled into normal availability instead of an urgent slot.
Turn retina evaluation visitors into qualified patients
Give every retina evaluation visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.