If you are a new patient and have scheduled an appointment, you may either complete and submit the on-line New Patient Data form or download, print and complete the BVA New Patient Forms and bring to your appointment.

To Print New Patient Forms Click the link below

HIPPA Privacy Notice 2013 (PDF)

New Patient Data (online option)

Please complete and submit the online form below. Once submitted, you will receive a confirmation email and request to print and complete the Patient History and Patient Consent forms to bring with you to your upcoming appointment.

Appointment Information - Required

Appointment Date: *

Month

Day

Year

Appointment Time: *

Hour

Minute

Appointment Location: *

Other Location:

Email Address - to receive confirmation message: *

Patient Information

First Name: *

Middle Initial:

Last Name: *

Address: *

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Date of Birth: *

Marital Status: *

Sex:

Home Phone:

Area Code

Phone Number

Work Phone:

Area Code

Phone Number

Cell Phone:

Area Code

Phone Number

Race: *

Preferred Language *

Other Preferred Language:

Follow Up Preference: *

Phone
Email
Mail

Optometrist:

Referring Physician:

How Did You Hear Of BVA?: *

Is This A Work Related Injury: *

If yes, please enter employee information. If no, please proceed to the next section.

Employer:

Employer Address:

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Insurance Information

Primary Insurance: *

I.D. Number: *

Group Number: *

Secondary Insurance:

I.D. Number:

Group Number:

Primary Insured/Responsible Party Information

Fill Out ONLY If Different From Patient Information

Name:

First Name

Last Name

Relationship to Patient:

Address:

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Contact Phone Number:

Area Code

Phone Number

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