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  • HEALTH HISTORY (3 Pages)

    Insurances require us to gather your health information at every visit, please submit your completed form atleast 1 business day prior to your appointment. To ensure proper authorizations are received ahead of time, make sure to include your insurance ID numbers, and/or an image of your card(s), even if you think we may already have it on file. Once you press the submit button to send your information, you will be redirected to a 'Thank You' page. Rest assured, this form and all the information contained in it, is HIPAA compliant and secure. If you are unable to complete this form online, please call either office and we will be happy to help you fill it out over the phone.
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  • Examination fees start at $115, but may be partially covered using Medical Insurance (including Medicare) or Vision Plan benefits. If you would like to use benefits at your visit, include your ID number(s) or pictures(s) of your ID cards below. This information is needed atleast 48 hours prior to your visit to ensure benefits are authorized in a timely fashion.

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  • Ocular History:



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  • Contact Lenses

  • To provide a contact lens prescription, our Doctors are required to do additional evaluation to ensure the eye is healthy enough to continue to support continued contact lens wear. This fee ranges from $50 to $80, depending on the complexity of the evaluation.

  • Social History

  • Medical History:

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