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.