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We want to thank you for visiting our web site. At this time, we would like to give you the opportunity to register as a new patient. Additionally, you will be given the opportunity to make an appointment which will be confirmed by e-mail or phone. By completing this form online, you will get the paperwork out of the way saving you time when you arrive for your appointment.
Oh yes, we still make appointments by telephone. Call us at 843-577-2674.
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Patient Information
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Name:
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Email Address:
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Home Phone:
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Work Phone:
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Are you an existing patient? Go to Making an Appointment
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Street:
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City:
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State:
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Zip:
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DOB:
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Age:
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Sex:
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Referred by:
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Insurance Information
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Primary Insurance:
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If Other, Company Name:
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SSN:
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Group Nbr:
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Insured’s Name:
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Sex:
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DOB:
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Relationship to Insured:
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Secondary Insurance:
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If Other, Company Name:
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SSN:
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Group Nbr:
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Insured’s Name:
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Sex:
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DOB:
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Relationship to Insured:
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Tell Us About Your Eyes
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I am currently wearing:
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Visual correction is used for:
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I am having difficulty with:
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The Reason For the Examination
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Routine Eye Exam
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Injury
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Swelling
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Cataract
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Contact Lenses
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Red Eye
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Itching
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Tearing
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Blurred Vision
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Infection
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Headache
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Double Vision
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Loss of Vision
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Pain
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Glaucoma
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Other
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Please List any other Reasons Below:
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Your Eye History and Family History
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Self
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Relative
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Self
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Relative
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Cataracts
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Eye Injury
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Diabetes
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Eye Surgery
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Heart Disease
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Eye Infection
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High Blood Pressure
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Vision Loss
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Thyroid
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Head Injury
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Sinus
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Retinal Detachment
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Cancer
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Macular Degeneration
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Arthritis
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HIV Positive
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List any medications you are currently taking:
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Making an Appointment
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I want to make an appointment now!
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Office Hours:
Monday and Wednesdays 9:30am - 5:30pm
Tuesdays and Thursdays 8:30am - 5:30pm
Friday 9:30am - 3:30pm
Please select dates and times below:
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My first choice for an appointment is:
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Month
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Day
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Year
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Time
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My second choice for an appointment is:
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Month
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Day
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Year
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Time
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Please tell us anything we need to know about your appointment below:
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Please confirm my appointment via:
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Email
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Telephone
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