Patient Registration

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Please read our Privacy Policy here.

 

Please complete the form below

Patient Information
Personal Information
Gender *
Eye History
Please check off any conditions you now suffer from
Glasses History (Skip if you don't wear glasses)
What glasses do you own?
Please check off any that apply
Contact Lens History (Skip if you don't wear contact lenses)
Please check off all that apply to you
Medical History
Please check off any current conditions you suffer from
Primary Insurance
Please bring all insurance cards with you to your appointment.
Secondary Insurance
If you have coverage through another plan/organization, please fill in the details below.
I have I have read and agree to the Privacy Policy *