Fill out our new patient form below, or download the PDF version to fill out and bring to your appointment.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Enter the last four digits of your social security # if I.D. # is not known.
  • Enter the last four digits of your social security # if I.D. # is not known.
  • I authorize the release of any medical or other information necessary to process my claim to my insurance company. I accept responsibility for payment of products and services and I have been offered a copy of Verona Vision Care's Notice of Privacy Practices.

    NOTE: All required fields need to be filled in order to sign and submit the form.

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Please note: Insurance may cover none or only part of your fees. If we do not accept direct payment from your insurance plan, payment is expected at the time of services and we will be happy to provide you with a receipt to submit to your insurance company for reimbursement. If your insurance does not pay as expected, you are ultimately responsible for all charges. We will be happy to assist you with your claims. Please give any forms to the receptionist. If you are using insurance: I authorize the release of any medical or other information necessary to process this claim. I accept responsibility for payment of products and services.

NOTICE: There is a contact lens evaluation fee in addition to the exam fee.

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Click the above link to view our Notice of Privacy Practices
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