Office Forms

Thank you for choosing American Vision at the Court for your eye care needs. To expedite the paperwork on your first visit, please complete and submit the following information so we can have your chart ready when you arrive.

Review our HIPAA Policy.

Before submitting this appointment request with the button below, please re-read your entries to ensure that your information is accurate and read the following privacy statement.

The information you supply via this appointment form is considered strictly confidential and will never willingly be shared with anyone without your explicit permission.  If you deem the information we ask for to be sensitive, the only way to ensure its absolute security is to discuss it with the doctor face-to-face.  We encourage you to do so by requesting an appointment by phone.

Name
Date of Birth
Daytime Phone
Mobile Phone
Email
Street Address
City
State
Enter zip code.
Vision Plan
Vision Number
Primary Policy Holder
Date of Birth of Policy Holder
If so, is this your first time wearing contact lenses?