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

 



Dr. Kirshner   |   Our Services   |   Eye Health   |   Eyewear   |   Contacts   |   Appointment   |   Contact Us   |   Home
© American Vision at the Court
Webmaster