Reception:
(252) 823-8295
Optical:
(252) 823-5200
About
Practice
Doctors & Staff
FAQs
Eye Care
Comprehensive Care
Dry Eye
Ocular Conditions
Eye Wear
Order Contacts
Aesthetic Services
Wrinkle Reduction
Microneedling
Age & Sun Spots
Facials
Patients
Contact Us
ONLINE BILL PAY
ORDER CONTACTS
NEW PATIENT FORMS
About
Practice
Doctors & Staff
FAQs
Eye Care
Comprehensive Care
Dry Eye
Ocular Conditions
Eye Wear
Order Contacts
Aesthetic Services
Wrinkle Reduction
Microneedling
Age & Sunspots
Patient Information
Contact Us
ONLINE BILL PAY
ORDER CONTACTS
NEW PATIENT FORMS
New Patient Form
Name
Date of Birth
MM slash DD slash YYYY
Address 1
Address 2
Phone Number
Is it okay to text this number?
Yes
No
Do you have any of the following ocular conditions:
Glaucoma
Macular Degeneration
Cataracts
Diabetes
Have you had any eye procedures or surgeries in the past?
Have you been seen by an optometrist in the last 3 years?
Yes
No
If yes, where and when were you last seen?
Do you were contact lenses?
Yes
No
What is the name of your MEDICAL Insurance? If known, please list the ID number:
Policyholder’s name:
Date of Birth
MM slash DD slash YYYY
What is the name of your VISION Insurance? If known, please list the ID number:
Policyholder’s name:
Date of Birth
MM slash DD slash YYYY
What days of the week/times work best for your schedule?
Although we cannot guarantee the exact day and time, we will do our best to accommodate your schedule. Although we are currently not scheduling new patients, we will place you on our waitlist with the information above and reach out as our office gets cancellations.
Protected by
CleanTalk Anti-Spam
