(In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.)

Contact Information

Guardian Information (if patient is under 18 years of age)

Patient Information

Primary Insurance Information

Secondary Insurance Information

Additional Insurance Information

Financial Assignment Information

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Acknowledgment of Notice of Privacy Practices (NPP)

Patient History

Vision Correction History (please check any that apply)

Sandy or gritty feelingSensitivity to light/glareStrabismus (crossed eye)Tired eyesWatery eyes

Glasses History (check all that apply)

What glasses do you own?

What glasses do you own?

Need sunglasses with UVProblems with current glassesProblems with glareProblems with night vision

Contact Lens History (check all that apply)

Check any that apply

Family History (check all that apply)

Allergies(please list)

General Medical History (please answer appropriately)

Do you have any of the following?

Referral Information

Why did you visit us?

Keep in touch

Visited our website

Questions and notes

Do you have a question? Concern? We want to know.