1.800.EYECARE

Schedule An Appointment

1.800.EYECARE

Medical & Patient Forms

To expedite your visit, please bring in a completed copy of our medical and patient forms to your scheduled appointment.

English Forms:

pdf-icon Patient Information Form
pdf-icon Medical History Form
pdf-icon Patient Contact and PHI Information Form
pdf-icon Well Vision Form

En Español:

pdf-icon Información Para Pacientes
pdf-icon Historia Clinica
pdf-icon Información Para Pacientes Insurance y Contacto
pdf-icon Información Para el Examen de los Ojos Saludables

What our customers are saying:

Ms. Yurashak’s took great care of patience in assisting me in selecting a frame that would be the best for my situation. She is warm and caring person who really does go the extra mile to help people.

- Cecilia P

I am very impressed with your staff. They are both professional and give excellent customer service. Plus, the glasses I got at Nationwide are the best I’ve ever had.

- Tim J.

I have been very pleased with the service I received from day one. I would recommend your office to everyone.

- Janine F