Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Primary Medical Insurance
Please bring all insurance cards with you to your appointment.
Secondary Medical Insurance
If you have coverage through another plan/organization, please fill in the details below.
Retinal Imaging/Dilation Consent
Contact Lens History
Privacy and Financial Policy