New Patient Form

Schedule Appointment

NOTE: If you are a new patient, please also fill out the New Patient Information Form here.

"*" indicates required fields

Name

This field is for validation purposes and should be left unchanged.

First Name*

M.I.*

Last Name*

Email Address*

Primary Phone Number*

Secondary Phone Number

Date of Birth*

Social Security Number

Address*

Street Address Address Line 2 City State ZIP Code

Gender*

Race*

Employer

Occupation

Do you wear contact lenses?*

Marital Status

Spouse's Name

Spouse's Date of Birth

Spouse's Employer

Medical History

Primary Care Physician

Primary Care Physician’s Phone Number

Please check if you have any of the following conditions:*

Diabetes

Glaucoma

Macular Degeneration

None of the above

Primary Insurance

Note: Please still bring all insurance cards with you to your appointment!

Responsible Party (Insurance Subscriber)

Member’s Date of Birth

Member’s SSN

Member’s Primary Phone Number

Member’s Address (if different from patient’s)

Street Address Address Line 2 City State ZIP Code

Privacy Policy

Please check the box below to verify you have read and agree to the Privacy Policy

Health Information Protection**

I have read and agree to the Privacy Policy

Testimonials

    
 
 
       G D 
 September 3, 2026
 
 
  My daughter Genny said she liked the doctor 😊
  
 
      G M 
 September 2, 2026
 
 
  Everything was great 👍
  
 
      S “ 
 September 2, 2026
 
 
  Sara was amazing!!!
  
 
      M M 
 August 31, 2026
 
 
  I’ve been getting my exams from Eyecare Specialties ( Dr. Jason Lake ) for over ten years now and consider myself truly blessed to have received outstanding care from him and his staff. Very friendly, professional and knowledgeable team. Hands down the best in the business. I Highly Recommend for your eye exams, contacts and eye glass needs. 10 out of 10 ( IMHO ).
  
 
      B C 
 August 28, 2026
 
 
  Great people. Very helpful.
  
 
      J M 
 August 28, 2026
 
 
  So the Rachel at checkout and who was it at check-in Tatyana Tatyana and Jerriella have done an awesome job at supporting all the details that I needed to accomplish today and I have had a wonderful surface experience here.
  
 
      M R 
 August 27, 2026
 
 
  Jordan, Katy and Jarielys were super.  They made my visit fun!
  
 
      A J 
 August 25, 2026
 
 
  The employees were so helpful and kind! I did not feel rushed (even though picking out new frames takes me a long time). They were professional and fun to work with! Strongly recommend! Specifically: Adrianne, Rachel, Ashley, and Katie!
  
 
      B B 
 August 23, 2026
 
 
  The staff were incredibly accommodating,  understanding,  and patient with me and my children.  Wonderful experience!
  
 
      C E 
 August 23, 2026
 
 
  They were amazing

New Patient Form

Medical History

Primary Insurance

Privacy Policy

Testimonials

Appointment Information

Schedule Now at Sedalia

Schedule Now at Warrensburg

Schedule Now at Lee’s Summit

Appointment Information

New Patient Form

Medical History

Primary Insurance

Privacy Policy

Testimonials

Request An Appointment

Appointment Information

Schedule Now at Sedalia

Schedule Now at Warrensburg

Schedule Now at Lee’s Summit

Appointment Information