Online Patient Registration Form - Direct Optical Center

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.

Online Patient Registration Form

  • Patient Information

  • Personal Information

  • Eye History

  • Glasses History (Skip if you don't wear glasses)

  • Contact Lens History (Skip if you don't wear contacts)

  • Medical History

  • Add a new row
  • Add a new row
  • Add a new row
  • Add a new row
  • Add a new row
  • Add a new row
  • Primary Insurance

  • Secondary Insurance

  • Privacy Policy