Your first visit to Pine Lake Optometry

Book your appointment here
Fill out the patient intake form below
On the day of your appointment, bring:
- Medical and vision insurance info
- Identification card
- Current glasses and contact lenses info
- List of medications
A list of accepted insurance plans is shown below. If you have any questions about your insurance, please call us at 425-868-3622.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

Country

(###)

###

####

Birthday

MM

DD

YYYY

Gender

What is your vision and medical insurance policy? If you are not the policy holder, please indicate so.

Please include Subscriber ID, Group #, or Policy Holder info.

Occupation and employer (if applicable)

When was your last eye exam?

How did you hear of us?

Message

How can we help you? Please let us know what your main concerns are for the visit.

Insurances we accept