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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

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Gender

Eye History

Eye History

Glasses History

Glasses History

Contact Lens History

Contact Lens History

Medical History

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Please check off any current conditions you suffer from

Primary Insurance

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Wellness Fundus Photo: Wellness photo of your retina will allow the Doctor to have an image to compare the health of your retina and optic nerve over the course of the time. Wellness photos are not covered by insurance and will be a fee of $39. 

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Personal Information