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Adults (18+ yrs old): 

  • Insurance Cards (All)
    • Medical
    • Vision
  • Primary Insured Information:
    • Social Security Number
    • Date of Birth
    • Address
    • Phone Number
    • Employer
  • Patient Social Security Number
  • Current Medication List
  • Any glasses you currently use
    • Daily Wear
    • Readers
    • Sunglasses
    • Safety/Occupational Glasses

 

Children (17 yrs & under)

  • Legal Parent/ Guardian (must be present)
  • Legal Parent / Guardian Information:
    • Social Security Number
    • Date of Birth
    • Address
    • Phone Number
    • Employer
  • Custody /Guardianship Papers
  • Insurance Cards (All)
    • Medical
    • Vision
  • Primary Insured Information
    • Social Security Number
    • Date of Birth
    • Address
    • Phone Number
    • Employer
  • Patient Social Security Number
  • Current Medication List
  • Any glasses you currently use
    • Daily Wear
    • Readers
    • Sunglasses
    • Safety/Occupational Glasses