First Name (Required)
Last Name (Required)
Email Address (Required)
Date of Birth (Required)
Phone Number (Required)
Alternative Phone Number
Are you a new patient? (Required)
How did you hear about us?
Health Insurance Name (Required)
Health Insurance ID Number (Required)
Vision Insurance Name (Required)
Vision Insurance ID Number
Preferred Doctor (Required)
No PreferenceDr. Vincent-RiemerDr. KnappDr. GouldDr. WhiteDr. Widmer
Type of Appointment (Required)
---MedicalRoutine VisionCRT FittingLasik Consultation
Preferred Day (Check all boxes that apply)
Monday Tuesday Wednesday Thursday Friday
Please type the following characters into the box below as you see them.
Please note that not all Doctors work every day. We will try to accommodate you to the best of our ability. If you have any questions, feel free to call us at (517) 337 – 8182 or send an email to firstname.lastname@example.org.
Health History Form
Returning Patient History Form
Records Release Form