YOUR Electronic Health record

RevolutionPHR is a secure, online personal health record provided to you by your eye care professional. Login here>>

Patient History Form

In everything we do, we aim to provide our friends, neighbors, and the surrounding community with valuable eye care and optometric expertise in a setting that is friendly, modern, and efficient.

Patient Registration Form

  • Patient Information

  • Personal Information

  • MM slash DD slash YYYY
  • Please enter a number from 0000 to 9999.
    (last 4 digits only!)
  • Eye History

  • Glasses History

  • Contact Lenses History

  • Medical History

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Primary Insurance

    Please bring all insurance cards with you to your appointment.
  • MM slash DD slash YYYY
  • Secondary Insurance

    If you have coverage through another plan/organization, please fill in the details below.
  • MM slash DD slash YYYY
  • Comments

  • Privacy Policy

Hours of Operation

Monday - Friday: 8.00 - 5.00
Saturday: Closed
Sunday: Closed

Schedule an Appointment