American Vision Eye Services

Our Services

Office Form
Thank you for choosing American Vision at the Court for your eye care needs. To expedite the paperwork on your first visit, please complete and submit the following information so we can have your chart ready when you arrive. Review our HIPAA Policy.
General Information (Note: Required fields are in red)
First Name
Middle initial
Last name
Date of birth
Address
City
State
Zip
Email
Daytime phone
Alternate phone
Vision Insurance Plan
Vision Insurance Plan Number
Name of Primary Policy Holder
Date of Birth of Primary Holder
Reason for Visit
Will you need a contact lens evaluation? If so, is this your first time wearing contact lenses? Yes No