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Patient Registration Form

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.


As part of our COVID-19 protocol we are now requiring our patients to undergo an Optomap Retinal exam in lieu of dilation to evaluate the inside lining of the eye. This procedure is being performed to lessen the time spent in our office. There is an additional fee of $35.00 for this test which is often not covered by insurance plans as it is considered a health screening. However, it can be billed to a medical insurance plan if there is a retinal disease diagnosis. Please speak to our staff for more information.