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Home » Hours & Location » Patient Registration Form

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.
  • Please provide us your email address.

  • Personal Information

  • Select date MM slash DD slash YYYY

  • Eye History

  • Glasses History

  • Contact Lens History

  • Medical History

  • Primary Insurance

  • Please bring all insurance cards with you to your appointment.
  • Select date MM slash DD slash YYYY

  • Secondary Insurance

  • Comments

  • Privacy Policy

  • This field is for validation purposes and should be left unchanged.

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We will be closed on Friday, May 23, through Monday, May 26, to allow our staff to enjoy a long holiday weekend with their families.

Saturday hours: We will be open 8:00am-1:30 pm on May 31, June 21 & 28.