Welcome Form

Registration Form

Please fill in the form below.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Cell Phone *

Area CodePhone Number
Reason for your Visit:
Do Your Eyes:
Interested in contacts

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Patient & Family Health History 1
Patient & Family Health History 2
Patient & Family Health History 3
Please list any medications including over-the-counter and oral contraceptives:
DILATION OF THE EYES: I have read and understood the attached statement on the main page about the need and reasons to hae my eyes dilated. *Dilation is a covered benefit with most vision insurances. This is an additional charge of $25.00 for this procedure, without insurance.
I wish to have my eyes dilated.

YesNo
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Registration Form