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Patient History 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.

    Please bring all insurance cards with you to your appointment.

    Please be advised there is a 24 hour cancellation policy. If you fail to notify us or miss your appointment, you will be subject to a $25 fee.

  • Patient Information

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

  • Date Format: MM slash DD slash YYYY
  • Please let us know how you were referred to our office.
  • Eye History

  • Glasses History

  • Please tell us what other kinds of glasses you own.
  • Contact Lens History

  • Medical History

  • Primary Insurance

  • Please bring all insurance cards with you to your appointment.
  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • If you have coverage through another plan/organization, please fill in the details below.
  • Date Format: MM slash DD slash YYYY
  • Comments

  • Privacy Policy

  • Bring insurance cards and photo id's.
    Bring current Rx: glasses or Contact Lenses
    Arrive 15 minutes prior to your scheduled appointment time
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OUR OFFICE IS NOW OPEN! Due to our new limited hours, please call or text our office to schedule an appointment. We are also offering curbside pick up for all glasses & contacts. Thank you for your continued patience and loyalty during these challenging times.