VisionSource! - North America's Premier Network of Private Practice Optometrists
North America's Premier Network of Private Practice Optometrists
NEW PATIENT PRE-APPOINTMENT FORM (We will not share your information with anyone, without your consent.)

PLEASE COMPLETE & SUBMIT BEFORE YOUR APPOINTMENT. ITEMS MARKED WITH AN ASTERISK (*) ARE REQUIRED FIELDS. (For drop down menus, hold control key down to select multiple items, where appropriate.)
Do you have an extra pair of glasses if your current glasses/contacts cannot be worn?*
*WE DO NOT ACCEPT VISION INSURANCE BUT WE CAN PROVIDE YOU THE PAPERWORK NEEDED TO SEND IN FOR REIMBURSEMENT.
*WE WILL FILE MEDICARE & BLUE CROSS/BLUE SHIELD FOR MEDICAL EYE CARE (CATARACTS, GLAUCOMA, DIABETES, ETC).

Preferred method of payment at time of visit:
THANK YOU FOR YOUR TIME! THIS INFORMATION WILL HELP US TO BETTER SERVE YOU!

PLEASE CLICK ON THE SUBMIT BUTTON BELOW TO SEND TO US. WE LOOK FORWARD TO SEEING YOU SOON!

***IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, PLEASE GIVE US 24 HOURS ADVANCE NOTICE. OTHERWISE, YOU WILL BE BILLED A $25 FEE FOR APPOINTMENT NOT KEPT***

May we check your medicines online? (If you answer "no" list them in the next section).

 

 
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