Please complete the form and submit online before your upcoming appointment.

Welcome Sheet
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Have you been examined or had glasses made here previously?
Today’s visit is for
(Contact exam is an additional $45-$65 charge)

Please present your insurance cards prior to examination.

Riverview Vision Center Notice of Privacy Practices

I have been informed of and given the opportunity to read the Riverview Vision Center Notice of Privacy in compliance with HIPAA regulations – to be signed by patients 18 years and older or their legal guardian.

Professional Fees are non refundable

Name
Name
First
Last