image

Optical_FSVB_2

Online 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.

Please also click on the following link , which is our financial policy.  Please print and sign, and bring with you to your exam, along with page 2 of our privacy policy.  Thank you!

Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.
Please provide the required field.