Please Note: We will be closing early at 1 PM on Tuesday, December 24th and will be closed on Wednesday, December 25th in observance of Christmas!

New Client Registration Form

BOOK APPOINTMENT

Please complete this form before your visit.

If you’d like to download the form, click here.

Owner's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Place of Employment

Employment Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

By adding your email, you can set up appointments and Rx refills online

Fees for all services are due at the time services are rendered. Personal checks are accepted with ID and when approved by Certegy. Visa, MasterCard, Discover, CareCredit, and cash are also acceptable forms of payment. We do not offer in-house payment plans, but you may inquire about Care Credit, a no-interest financing option. We are also happy to provide printed estimates upon request of diagnosis. *

I have read and understand

Emergency Contact *

First

Last

Cell Phone

Relationship to you

Place of employment

Home Phone

Work Phone

Owner Signature *

Clear Signature

Date *

Phone

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