Become a Patient

« indicates that this field is required. Please complete required fields.

Name:

(parent/guardian if minor)

Address: (1)

Address: (2)

City:

Zip:

« Please provide at least one phone number

Home Phone:

Day Phone:

Cell Phone:

E-mail Address:

Employer:

Occupation:

Do you wear contacts?

Yes / No

Interested?

Yes / No

Whom May We Thank For Referring You To Us?

Who is Responsible for Paying This Account?

Preferred Payment?

Cash / Check / Credit

Insurance?

Yes / No

Company Name:

Member Number:

Relationship:

Self / Spouse / Child

Insured Date of Birth:

You must enter the number to the far left in the text box to send the form information. This prevents abuse of this form.

Or call us at (919) 968-6300 to schedule your appointment!