New Patient Form

Fill out our new patient form below, or download the PDF version to fill out and bring to your appointment.

Required fields are marked with an asterisk*

/ /
/ /
Enter the last four digits of your social security number if I.D. Number is not known

Please note: Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, payment is expected at the time of services and we will be happy to provide you with a receipt to submit to your insurance company for reimbursement. If your insurance does not pay as expected, you are ultimately responsible for all charges. We will be happy to assist you with your claims. Please give any forms to the receptionist. If you are using insurance: I authorize the release of any medical or other information necessary to process this claim. I accept responsibility for payment of products and services.

NOTICE: There is a contact lens evaluation fee in addition to the exam fee.

HIPPA Privacy Act

Click Here to View the HIPPA privacy act for Verona Vision Care. Then you may check the box below to proceed.

Please add your signature (or have your guardian, if under 18) by clicking the button below.