Patient Forms

New Patient: Please print and complete all of the forms listed below or New Patient Form Package. You can bring your paperwork to your appointment or fax it to (770) 640-6789 - Attn: Front Desk.

• Demographic Form
• Insurance Form
• Financial Agreement
• Patient Privacy Notice

Previous Patient: Upon check-in, we will verify your current information on file.

Record Release Form: If you need to request records for yourself or another doctor's office, please print and fill out the "Record Release Form" and fax to: (770) 640-6789 - Attn: Front Desk. Releasing records can take up to 2 business days for active patients and may take longer to retrieve old records. Thank you.

• Record Release Form

Payment Options

We accept the following forms of payment: Cash, Check, MasterCard, American Express, Visa, Discover, and Care Credit.

CareCredit (Medical Payment Plan)

As a service to our patients, we are pleased to offer the CareCredit card, the nation's leading patient payment program. CareCredit lets you begin your procedure immediately, then pay for it over time with low monthly payments that are easy to fit into your monthly budget. So, you can begin your vision care today and conveniently pay with low, monthly payments.

With CareCredit, you pay no up-front costs, no pre-payment penalties and no fees. Plus, CareCredit is a revolving credit line for additional treatment or add-on charges, without the need to re-apply. It only takes a few minutes to apply for CareCredit and you may receive an online decision in seconds! Apply now or see our staff for more details.

• 6 Month Plan
• No Interest if the balance is paid within the specified time period
• Low Minimum Monthly Payments
• Pay Online
• Mobile App