Patient Name *

First Name

Last Name

Patient Date of Birth *

MM

DD

YYYY

Phone *

(Cell Phone Recommended to Receive Texts)

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SMS Consent

By checking this box, you consent to receive text communications from Sunshine Optometry, to the number provided above. - Privacy Policy can be viewed at [https://www.sunshineoptometry.com/privacy-policy] - Standard SMS rates and terms may apply. - You may opt out at any time by texting STOP.

Yes, I agree to receive text messages

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Purpose of Visit *

Check all that apply

Glasses Eye Exam

Contact Lens Exam

Urgent Care Office Visit

Glasses Styling, Adjustment, or Repair

Lumenis Optilight Intense Pulsed Light Therapy (IPL)

Specialty Contact Lens Exam (Scleral, RGP, Custom Soft)

Other ( Please Indicate Below )

Select a Provider

First Available

Dr. Adrig Sarian (Available Mon, Tues, Thur, Fri)

Dr. Matthew Thornton (Available Wed, Thur)

Notification of Policies *

Please bring your glasses, sunglasses, reading glasses, contact lenses, identification, payment method, insurance card, and a list of current medications. Co-payments are required to be collected at the time of service. We make every effort to mutually respect scheduling conflicts, and require at least 24 hour notice if you need to cancel your appointment. A no-show or late cancellation fee of $40 will apply. We reserve the right to modify your appointment if you do not confirm. Full store policies can be viewed on the policy page.

Yes, I have read and agree to Sunshine Optometry Policies