Telehealth Form Complete Our Telemedicine Form Name(Required) First Last Phone(Required)Email(Required) Which eye is it?(Required) Right Left Both When did it start?(Required) What are your symptoms?(Required) redness itching discharge pain irritation swelling vision change foreign body sensation other Select AllWhat color was the discharge? Did you treat it in any way, shape, or form?(Required) Upload Image(s)Max. file size: 31 MB.Take a picture of the injured eye with your cell phone. Upload the images here.Comments(Required)Describe the problem briefly and let us know what is the best time to reach you.