Name *FirstMiddleLastDate of Birth *Cell Phone NumberWork Phone NumberHome Phone NumberMailing Address *City *State *Zip Code *Email *EmailConfirm EmailAre you a new patient? *YesNoDo you have vision insurance? *YesNoInsurance Company:Ex: Blue Cross Blue Shield, United Healthcare (UHC), Medicare, Superior Vision, Crescent, Humana, Optum/Spectera, Davis Vision, VSP (Vision Service Plan), Cigna, Aetna Name of Policy Holder:Member ID Number:Reference your insurance card for the member identification number.Preferred Appointment TimeNo PreferenceFirst AvailableEarly MorningMid-DayLate-DaySaturdayPreferred Callback TimeMorning AfternoonEveningAnytimePreferred Callback LocationCellWorkHomeI give you permission to send a confirmation email. *YesNoDate of Last Eye ExamCommentsPhoneSubmit Forms – To save time, you may bring the following privacy forms already filled out to your exam. Please click the link below, print, and fill out the highlighted information. We look forward to seeing you! Click here for HIPPA Forms
