Reg Form
Patient Information
If under 18 years of age, provide name of parent or guardian. (Enter NA if 18 or above 18 years of age)
Please fill below information if different from above.
Is your annual household income greater than $45,000.00 per year?
Do you currently wear eyeglasses? If so, please bring them to your eye exam appointment.
Who is your primary employer? If unemployed, write N/A.