Cary, NC: 919.367.5555
Durham/RTP, NC: 919.544.2020

Online Patient Registration

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Select a Practitioner

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Patient Information

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First Name *

Last Name *

Address 1 *

City *

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Zip *

Home Phone *

Work Phone

Cell Phone

E-Mail *

Date of Birth

Social Security #

Employment/School Status

Attending School
Employed
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Stay-at-Home

Employer

Family Doctor

Insurance Company

Referred by:

Gender

Male
Female

Marital Status

Single
Married
Divorced
Widowed

Are you taking ANY medication? If yes, which medication(s)

With your best vision correction on have you suffered from any of the following:

near vision blur

YES
NO

distance vision blur

YES
NO

middle distance vision blur

YES
NO

(dashboard/computer) double vision

YES
NO

headaches

YES
NO

seeing spots/lines

YES
NO

seeing flashes

YES
NO

seeing haloes

YES
NO

dry eyes

YES
NO

water eyes

YES
NO

pain in/around eyes

YES
NO

red eyes

YES
NO

changing focus from near to distance

YES
NO

changing focus from distance to near

YES
NO

outdoor glare

YES
NO

indoor glare

YES
NO

eye strain

YES
NO

Accepted Insurance Plans

We accept most major medical and vision plans to better serve our patients. Currently, Triangle Visions accepts the following insurance plans:

Aetna
AmeriHealth
BCBS regular
BCBS State (medical only)
Cigna
Community Eye Care
Mamsi
Medicare
Opticare
Partners (medical)
Piedmont Administrators
Superior Vision
United Health Care
Vision Service Plan (VSP)
Wausau
Private Health Care Systems (PHCS)

The list of plans changes periodically, so please be sure to call one of our patient care coordinators with specific questions (919.544.2020 or 800.613.EYES).

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Contact Us

Cary | Holly Springs - Optometrist Map
3460 Ten Ten Road, Suite 112B • Cary, NC 27518
Phone 919.367.5555 • Fax 919.367.5559

Durham | RTP - Optometrist Map
2216 East NC Highway 54 • Durham, NC 27713
Phone 919.544.2020 • Fax 919.433.0298

Proud Members of

North Carolina State Optometric Society
American Optometric Association
Cary Chamber of Commerce