Eye Surgery | Merritt Island, FL | Eye Clinic & Laser Institute

NEW PATIENT REGISTRATION FORM

New Patient Registration Form

We sincerely appreciate you choosing us for your eye care needs and we look forward to getting to know you. If you are new to our practice please click the "New Patient Registration" button below. This will open a new page and you will be able to fill out the form and submit this to us. When you arrive in office you will need to provide a valid photo ID and updated insurance cards. You will also need to provide signatures IN PERSON. We will have the necessary forms for you to sign, but please be familiar with our policies before you arrive.

To use the New Patient Registration form you will use the link below to download the form and save it to your computer. Once you have the form downloaded you can fill it out. After filling it out, save your work and then submit the form to us by emailing us the file. We will receive your form and have it ready for your to sign in person.

Thank you in advance for preparing your paperwork, we appreciate your cooperation.

Please submit your forms at least 48 business hours prior to your appointment to ensure we receive prior to your appointment.
You will receive a confirmation email from us once your paperwork is received, if you do not receive a confirmation please contact us to verify we received your paperwork.
This feature is only available on a PC or a Tablet.

If you can't download and save the form you can print and fill out by hand and bring to the office.

If you have any questions about filling out the form please contacts us for assistance.

New Patient Registration

Email Your File Here

Merritt Island

1045 N Courtenay Pkwy Merritt Island, FL 32953

321-453-3937

Melbourne

232 S Wickham Rd Melbourne, FL 32904

321-953-3937

Port St. John

6725 N Highway US 1 Cocoa, FL 32927