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Registration Form

Please complete this form as it lets us know the history and current state of your health. Also let us know what questions, concerns, and goals your have regarding your eye health or vision on the form. You can complete the information below and submit the form online electronically or you prefer print out the form, fill it 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 Registration Form

  • Patient Information

  • Personal Information

  • Eye History

  • Glasses History (Skip if you don't wear glasses)

  • Contact Lens History (Skip if you don't wear contacts)

  • Medical History

  • Primary Insurance

    Please bring all insurance cards with you to your appointment.
  • Secondary Insurance

    Please bring all insurance cards with you to your appointment.
  • Privacy Policy