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  • Emergency Contact Person's Number
  • Emergency Contact Persons's Relation
  • Be Specific so we can Assess your Visual Needs at Work and Leisure & Set up Corp. Discount & save $500/company
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  • If you heard about us via Friend/Patient/Doctor please leave their name. If you heard about us via Google please write search term used. Leave blank otherwise.
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  • MEDICAL INSURANCE INFO. (REQUIRED FOR ALL PATIENTS): To offer a Medical Credit for LASEK and for Office Visits/Second Opinions we must confirm that we accept your plan, that it’s active, and if you need a Referral to see a Specialist. We also need this so we can bill your insurance for punctal plugs to treat Dry Eye Syndrome & speed healing after surgery. We will bill only with your permission. We will accept as full payment whatever your insurance pays—unless it is $0 because you didn’t get a referral, or if you’re inactive, or if your referral isn’t used up. Call Kaye at PM Medical Billing at (516) 922-1561 if you have
  • SECONDARY INSURANCE (Medical or Vision): CAN HELP COVER MORE OF YOUR PROCEDURE COST: