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Please fill out this form as completely and detailed as possible, so that we may better serve you.

Personal Information

Eye Health Information

Medical Health History

By signing below, you acknowledge that the above information is accurate and complete. The patient/guardian accepts financial responsibility for any unpaid balances for services rendered. Unpaid balances after 45 days become the responsibility of the patient.

Social History

This information is kept strictly confidential. However, you may discuss this portion directly to the doctor if you prefer

Review of Systems

Do you currently or have you ever had any problems in the following areas?








Ears, Nose, Throat, Mouth



Additional Information

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Exclusive Offer

Now offering 50% off prescription lenses with purchase of any frame*

*Oakley sunglasses and CR-39 excluded from sale. May not be combined with insurance or any additional discounts.

Office Hours

Location Hours - South Windsor Office

Monday9:00 am8:00 pm
Tuesday9:00 am8:00 pm
Wednesday9:00 am8:00 pm
Thursday9:00 am8:00 pm
Friday9:00 am8:00 pm
Saturday9:00 am8:00 pm
Sunday10:00 am6:00 pm
Day Open Close
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00 am 9:00 am 9:00 am 9:00 am 9:00 am 9:00 am 10:00 am
8:00 pm 8:00 pm 8:00 pm 8:00 pm 8:00 pm 8:00 pm 6:00 pm




Location Hours - Newington Office

MONDAY 9:00 am 8:00 pm
TUESDAY 9:00 am 8:00 pm
WEDNESDAY 9:00 am 8:00 pm
THURSDAY 9:00 am 8:00 pm
FRIDAY 9:00 am 8:00 pm
SATURDAY 9:00 am 6:00 pm