New Patient Form

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

"*" indicates required fields

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

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

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

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

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

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