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