Online Patient Registration Form

  • Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.
  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide us your email address.
  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0000 to 9999.
  • Eye History

  • Glasses History

  • Contact Lens History

  • Medical History

  • Primary Insurance

  • Please bring all insurance cards with you to your appointment.
  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • Comments

  • Privacy Policy

Marion, VA Office

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Cedar Bluff, VA Office

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 9:30 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

Bristol, TN Office

Monday: 8:00 AM - 5:00 PM
Tuesday: 8:00 AM - 5:00 PM
Wednesday: 8:00 AM - 5:00 PM
Thursday: 8:00 AM - 5:00 PM
Friday: 8:00 AM - 5:00 PM
Saturday: Closed
Sunday: Closed