lock icon Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Most medical health insurance plans do not cover Routine Vision and or dental plans. Vision Plans are typically considered supplemental coverage and typically have a specific ID# or use your SSN. It is the member's responsibility to know their insurance coverage and to provide information at the time of appointment.

Appointment cancellations need to be made 24 hrs in advance to your scheduled visit to avoid cancellation fees.

Step 1 of 9

Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*

Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address*

Please provide us your email address.

Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured

Holiday Closure Notice

We’ll be closed for the holiday season on the following dates:

Nov 20: 8am – 5pm

Nov 21: 9am – 5pm

Nov 22: 9am – 2pm (closing early)

Nov 23-26: CLOSED

Nov 25: CLOSED

Nov 26: CLOSED

Dec 25-26: CLOSED

Jan 1: CLOSED

Warm wishes for a joyful holiday season and a brilliant New Year!

Eye Emergency

Online Patient Registration Form

Step 1 of 9

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

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RidgeView Optometry