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