Make an Appointment

Name :

Street Address:

City: State: Zip:

Phone Number: -

Date of Birth (mm/dd/yyyy):

Email Address:

Confirm Email Address:

Check One: Current patient: New Patient:

Insurance:

How Did You Hear About Us:

Which office would you like to visit? :

Requested date for appointment (mm/dd/yyyy):

Requested appointment time:

Type of Visit:

Please confirm my appointment via: Email: Phone:

Please use the space below for any additional comments and to give us the insurance information on your insurance care. We will then verify your information before you arrive.

If you are a new patient and would like to save yourself some time at our office by completing your initial paperwork prior to your appointment, please complete our Patient Information Questionnaire and bring it to your appointment or you can fax it to us at . Our HIPAA Notice is also available below. You will need Adobe Acrobat to view the paperwork.

If you are unable to open the files click on the Adobe icon to download the software.

Tips on using health insurance or vision discount plans, including a list of insurance companies we accept is also available.

HIPAA Notice - Effective 4/14/2003 ALL doctors, hospitals, health insurance companies, etc. must come into compliance with HIPAA, the Health Insurance Portability and Accountability Act of 1996. After 04/14/2003 all doctor's offices, hospitals etc. will ask you to sign an Acknowledgement of Receipt (AOR) of their Notice of Privacy Policies (NPP) prior to treatment. We recommend that you review this document at your leisure, prior to your appointment. The link above will take you to an online copy of our NPP. If you would like, you can print out our NPP for your review. Thank you. We look forward to seeing you soon.

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