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)

Glasses History (check all that apply)

Contact Lens History (check all that apply)

Family History (check all that apply)

PATIENT HISTORY

General Medical History (please answer appropriately)

Referral Information

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Questions and notes