Testimonial Intake Form

Thank you for trusting Dr. Troy White with your vision and wellness! Our passion is helping you live comfortably and see clearly. By sharing your experience, you can help others who might be suffering from similar symptoms find the relief they deserve.

Please take a moment to answer a few quick questions about your journey. We truly appreciate your time and feedback!

Your Contact Details

First & Last Name(Required)

Email Address(Required)

How would you like your name to appear publicly?(Required)

Full Name (e.g., Jane Doe)

First Name and Last Initial (e.g., Jane D.)

Initials Only

Gender,age (e.g., Female, age 25)

What brought you into our office?(Required)

What symptoms or vision issues were you experiencing before seeing Dr. White? (e.g., chronic headaches, neck/shoulder pain, digital eye strain, dizziness, or blurred vision?)

What was your experience like during your visit and testing?(Required)

How did Dr. White and the team make you feel? Did our specialized testing (like our Neurolens measurement) help you understand your symptoms better?

How has your life changed since receiving your new glasses?(Required)

We love hearing about your results! Have your headaches or eye strain improved? What can you do comfortably now that was difficult before?

Is there anything else you’d like to say about Dr. White or the team?

Optional

Permission to Share Your Story(Required)

Yes, you have my permission to publish my review using my selection in question 2.

Yes, but please keep my review completely anonymous.

No, please keep this feedback internal for Dr. White and the team only.

To help other patients searching for answers, do we have your permission to share your written review on our website or social media? Note that your medical details will remain private and only the information you provided above will be shared.