New Patient Form

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

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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

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Testimonials

    
 
 
       M P 
 October 15, 2026
 
 
  Fantastic experience with this location, my first time here. Everybody was so nice and I was really impressed with the professionalism.
  
 
      C M 
 October 13, 2026
 
 
  Dr Gelvin is very good & listens to concerns. Kaylea was so sweet & patient in choosing the best frames for my shape of face.
  
 
      R H 
 October 13, 2026
 
 
  The staff and doctors are great. Thoroughly explained every part of my visit.
  
 
      D H 
 October 11, 2026
 
 
  Super efficient facility. This staff is running like a well oiled machine! Well worth the 45 minute drive as they are very professional, easy to talk to, upbeat and get my medical grade contact orders in correctly every year (Not an easy task).   Dr. Orson always reviews any issues and I leave feeling secure about the progress of my vision issues through the years.  Highly recommend.
  
 
      K G 
 October 9, 2026
 
 
  My first time at Eyecare Specialties and everyone was so friendly, helpful and knowledgeable. Sam helped me choose a pair of frames. The one pair that I wouldn’t have otherwise tried that she suggested were very flattering and comfortable and they’re the ones I decided on! Also, needed a pair of quality sunglasses and again she picked out a pair that were perfect for me. Just a great experience overall and I would highly recommend them. If I could give more than 5 stars I certainly would.
  
 
      D R 
 October 8, 2026
 
 
  Dr Gelvin was fantastic!! Rachel, Jordan, Kennedy and the two girls at the front were great!!
  
 
      A C 
 October 8, 2026
 
 
  Rachel at the check out desk and Ashley the optician were amazing!!! Helped me pick out my glasses, and were patient centered!
  
 
      K M 
 October 8, 2026
 
 
  Very helpful.
  
 
      R D 
 October 7, 2026
 
 
  Everyone was so nice & helpful
  
 
      J A 
 October 7, 2026
 
 
  Everyone who works there is very nice and professional. They know what they're doing. I highly recommend them to friends, family and anyone else.

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New Patient Form

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