• NEW PATIENT REGISTRATION

  • In order to provide you the best possible care, please complete this form
    and bring it to your first appointment. All information is strictly CONFIDENTIAL.

  • Contact Information

  • Guardian Information (if patient is under 18 years of age)

  • Patient Information

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    Pick a Date
  • Primary Insurance Information

  • Secondary Insurance Information

  • Additional Insurance Information

  • Financial Assignment Information

    I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

  • Clear
  •  - -
    Pick a Date
  • PATIENT HISTORY

  • Glasses History (check all that apply)

  • Contact Lens History (check all that apply)

  • General Medical History

    (please answer appropriately)
  • Referral Information

  • Keep in touch

  • Questions and notes

  • Should be Empty: