Patient Registration Form

Please complete the information below and either:

This form is delivered to your doctor through a secure Internet connection.

First Name

Last Name

Birthdate required

Street Address

City

Region/State/Province

Postal / Zip code

Email

Phone

Eye History

Eyeglasses / Contact lens history: Required

I wear eyeglasses for driving /distance

I wear eyeglasses for reading

I wear contact lenses

Brand of Contact Lenses:

Date of Last Eye Exam required

Name of Previous Eye Doctor

Date of Last Physical Exam required

Pharmacy:

Name of Primary Care Doctor

Address

Member ID:

Upload Insurance Card

Upload supported file (Max 15MB)

Upload Driver's License

Upload supported file (Max 15MB)

Upload Vaccine Card

Upload supported file (Max 15MB)

Phone

Group ID:

If so, list allergies to medicine:

List of Medications currently taking:

List of Vitamins/Supplements currently taking:

Thanks for submitting!