If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]
951-687-7100 H
H

951-687-7100

Online Patient Registration Form

Online 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.

Personal Information

Eye History

Please check off any current conditions you suffer from

Glasses History (Skip if you don't wear glasses)

What glasses do you own?

Please check off any current conditions you suffer from

Contact Lens History (Skip if you don't wear contacts)

What is your typical wearing schedule?

Medical History

Primary Insurance

Please bring all insurance cards with you to your appointment.

Secondary Insurance

If you have coverage through another plan/organization, please fill in the details below.

Privacy Policy

Office Hours

DayOpenClosed
MondayClosed
Tuesday9am6pm
Wednesday9am6pm
Thursday9am6pm
Friday9am5pm
Saturday9am3pm
SundayClosed
Day Open Closed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Closed 9am 9am 9am 9am 9am Closed
6pm 6pm 6pm 5pm 3pm