Patient Registration

If you have trouble viewing the form below, of if you find it difficult to distinguish the appropriate boxes, please download the PDF version of this form using the link below. Print out the form, complete it, and return it to our office in person or by fax to 719-576-6955.

pdficon_smallRegistration Form PDF


Receive a $15 coupon towards your next pair of glasses or sunglasses when you fill out your patient registration form online!


Step 1 of 6

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  • PART 1: Patient Information