New Patient Form

New Patient Form

Basic Information
Contact Information
May we leave a detailed message on your phone?
Provider's Information
Insurance Information
Vision Insurance
*Optional* Upload front picture of vision insurance card
*Optional* Upload back picture of vision insurance card
Medical Insurance
*Optional* Upload front picture of medical insurance card
*Optional* Upload back picture of medical insurance card
Health History
Do you wear either of the following?
Are you satisfied with the vision and comfort of your contact lenses?
Have you ever been diagnosed or treated for the following health problems?
Are you having any of the following vision concerns?
Allergies

Is there a family medical history of any of the following?

Check all that apply
Please list relationship (Mother, Father….)
Have you ever been diagnosed or treated for the following eye conditions?
Medications

Contact Info

  • Address:
    825-B Merrimon Ave
    Asheville, NC 28804
    Get Directions
  • Phone:
    (828) 236-0099
  • Fax:
    (828) 236-1236
Connect:
admin none 9:00 am - 12:00 pm, 1:00 pm - 5:00 pm 9:00 am - 12:00 pm, 1:00 pm - 5:00 pm 9:00 am - 12:00 pm, 1:00 pm - 5:00 pm 9:00 am - 12:00 pm, 1:00 pm - 5:00 pm 9:00 am - 12:00 pm, 1:00 pm - 5:00 pm By Appointment Closed