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.

Personal Information

Gender*

Eye History

​​​​​​​Please check off any current conditions you suffer from

Glasses History

Do you wear glasses? *

Contact Lens History

Do you wear contact lenses? *

Medical History

Please check off any current conditions you suffer from

Primary Insurance


Please bring all insurance cards with you to your appointment.

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