Skip to main content


We're located in the Country Charm Shopping Center

Call: 419-874-3661 Request Appointment

Home » Contact Us » Online Patient Registration Form

Online Patient Registration Form

Please download the form below and submit it online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Medical History Formlock icon


Request Appointment
With our Eye Doctor