New Patient Information

Completing and submitting the following information prior to your appointment will help us make your visit more punctual and thorough.
If yes, please enter your PCP name and location below.
To help our office better serve your specific needs, please check all that apply. If none apply, please check none.
We do verify both your general vision and medical insurance benefits prior to your appointment; however, it is important to remember all insurance plans are different and may not cover equally for certain procedures. We use the required insurance websites to verify benefits, but they do not include all details and changes associated with Obamacare. The insurance companies present the most accurate information possible with a disclaimer saying that they cannot guarantee accuracy. The patient and/or policy holder is ultimately responsible for all charges.

All PHI information in this form is secure and encrypted.