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Patient Registration Form

  • 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.

  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide us your email address.
  • Personal Information

  • MM slash DD slash YYYY
  • Glasses History

  • Medical History

  • Family History

  • Dialation

    Dilation of the pupils of your eyes is an important part of a comprehensive eye exam. It allows your doctor to detect many eye diseases. Although we feel it is important to perform this test, if for some reason you wish not to have this done you may defer this test until a later date.
  • Privacy Policy

  • This field is for validation purposes and should be left unchanged.

We only accept the following insurances: Medicare, Humana VCP, VSP, UHC Spectra and UHC MDCD.

We accept the following types of payments: cash AMEX, Discover, Mastercard, and Visa. We do not accept personal checks. All balances must be paid in full when glasses or contacts are received.