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.

* Indicates required fields

First Name *
Initial
Last Name *

Date of Birth *
Daytime Phone *
Mobile Phone

Email *
Address *

City *
State
Zip *

Vision Insurance Plan
Vision Insurance Plan Number

Name of Primary Policy Holder
Date of Birth of Primary Holder

Will you need a contact lens evaluation?

If so, is this your first time wearing contact lenses? Yes No

Before submitting this appointment request with the button below, please re-read your entries to ensure that your information is accurate and read the following privacy statement.

The information you supply via this appointment form is considered strictly confidential and will never willingly be shared with anyone without your explicit permission. If you deem the information we ask for to be sensitive, the only way to ensure its absolute security is to discuss it with the doctor face-to-face. We encourage you to do so by requesting an appointment by phone.