Grant Vision Care, Inc.: New Patient Forms

Welcome to Grant Vision Care, Inc's secure New Patient Form. We ask that you take the time to fill out the forms with your complete medical history. Please complete all pages and upon hitting submit your forms will come directly to the office for your upcoming appointment. If you have questions about the forms you can call the office at (330) 923-9951.

By submitting the the new patient form you are agreeing that you have been offered a copy of the View Patient Privacy Policy.

Insurance Financial Waiver
By submitting this New Patient I understand that the services and /or supplies provided by Grant Vision Care may not be considered eligible for benefits (e.g., they may be determined to be not medically necessary, non-covered or investigational).

I understand that my health/eye insurance coverage has certain restrictions and limitations, such as authorization requirements and non-covered services and/or supplies. Since I have chosen to obtain the services and/or supplies, I agree to be financially responsible for any and all related charges, if they are not covered by my insurance.

New Patient Page