New Patient Forms
We are excited that you are becoming a new patient with us! First, we need to know some things about you. Please provide as much information as possible so that we can better serve you. Thank you! Your personal information is hosted on a secure site.
Your personal information is being transferred on a secure and encrypted webpage.
Please enter your information.
Please select your vision insurance provider and enter your member id
If patient is the primary subscriber, please leave the first answer as [No].
Please select your medical insurance provider and enter the information.
Please provide the subscriber's information.
List any reasons inside the box.
Describe any vision complaints you are currently having inside the box.
Please provide as much information as possible.
Please answer as much as you can.
Please initial and sign the agreement to submit the forms.