JAY A. NEWSOME, O.D., SUSAN D. MENCARINI, O.D. & DIANNA INTHAVONG, O.D.
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Patient forms

Patient Forms

Our office has recently upgraded to an Electronic Medical Record system. Below is link to our new medical history forms. Whether you are a returning patient or you will be visiting us for the first time, please use the link to fill out/ update your forms before coming into the office. It is very important that these forms be completed before your visit. If you're not able to access the link, please email us at [email protected] for us to send a pdf copy.

​Thank you for your cooperation.
Medical History Form
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Contact Us:
305 Pollasky Ave.
Clovis, CA 93612

(P) 559-298-2120
(F) 559-299-3741

email: [email protected]
Office Hours:
Mon - Fri 8:30 am - 5:00 pm
Closed 12:00 pm - 1:30 pm



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  • Home
  • Office News
  • Our Doctors
  • Our Services
  • Contact Lenses
  • Patient Forms
  • Location