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.

Patient Information

Personal Information

Gender*
Preferred Language*
Preferred Language*
Race*
Ethnicity*
Marital Status
Employment Status
How were you referred to our office?
Communication Preference

Eye History

Please check off any current conditions you suffer from

Glasses History

Do you wear glasses?*

Contact Lens History

Do you wear contact lenses?*

Medical History

Do you drink alcohol?
Do you smoke?
Please check off any current conditions you suffer from

Primary Insurance

Please bring all insurance cards with you to your appointment.

Comments

Privacy Policy

Health Information Protection*

Privacy Policy

Contact Info

  • Address:
    831 Vermont Street
    Lawrence, KS 66044
    Get Directions
  • Phone:
    (785) 843-5665
  • Fax:
    (785) 841-3153
Connect:
admin none 8:00 AM - 5:30 PM 8:00 AM - 5:30 PM 8:00 AM - 5:30 PM 8:00 AM - 7:00 PM 8:00 AM - 5:00 PM 8:00 AM - 12:00 PM Closed optometrist # # #