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Home » Contact Us » Patient Information Form

Patient Information Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

We do NOT accept insurance, so do not fill out the insurance section of the form.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

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The CDC has recommended that all routine, non-medically necessary eye care be deferred until further notice in order to slow the transmission of COVID-19 through our community. Currently, we will be available for eyecare but on a limited, pre-arranged basis for urgent or medically necessary eye care. We will reevaluate the circumstances as they evolve and may resume normal hours of operation mid-April, depending on the situation. However, we may need to continue our current course of action for a longer period of time.