Authorization for Medical Records ReleasePrivacy Practices РRefractions

Patient Registration

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

Please bring the following items on your visit:

Insurance Cards(s)

Photo I.D.

Co-Payment (cash, check, credit card)

Your prescription eyeglasses and/or contact lenses

List of medications/eye drops