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Name *

First

Middle

Last

Date of Birth *

Cell Phone Number

Work Phone Number

Home Phone Number

Mailing Address *

City *

State *

Zip Code *

Email *

Confirm Email

Are you a new patient? *

Do you wear contact lenses or would you like a contact lens fitting? *

Do you have vision insurance? *

Insurance 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 Time

Preferred Callback Time

Preferred Callback Location

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Date of Last Eye Exam

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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!

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