New Patients/Forms

Contact Lens:

Family History:

Is there family history – not you – with any of the following conditions:

Refraction Service:

A refraction is the test to determine your glasses prescription or refractive error. Most insurance companies do not pay for this service. You may be responsible for the $40.00 in addition to any Co-pay, Co-Insurance, or Deductibles that you will pay upon check-out.

HIPAA Privacy Notice:

By signing below, you fully understand the information contained in the HIPAA Privacy Policy documents regarding the confidentiality of your health records. If the patient is a minor, the responsible party must sign.