New Patient Forms - Main Street Optometry - Vision Source

The following forms are available online for your convenience, simply click on the form name to view the form. They are available in adobe .pdf format. If you don't have the Adobe Reader software, please click here or on the icon below the forms in order to install the reader software on your home computer. Please fill out all printable forms and bring them to the office with you.

New Patient Forms

New Patient Information / Medical History Form

HIPAA Disclosure / Billing & Financial Policy

GDxVCC & Oculus Easyfield Screening

Read/Print Main Street Optometry's HIPAA - Notice of Privacy Practices

Main Street Optometry - A proud member of the Vision Source network of premier eye care practices is located in Michigan's Washtenaw county in Dexter (near Ann Arbor - Chelsea), and in Livingston county in Pinckney (near Brighton - Howell).

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DEXTER MICHIGAN OFFICE 8089 Main Street Suite 1 Dexter Michigan  48130 Phone: 734.424.9230 Fax: 734.424.2576 dexter@mainstreetoptometry.com		PINCKNEY MICHIGAN OFFICE 1245 E. Main Street P.O. Box 317 Pinckney Michigan 48169 Phone: 734.878.7444 Fax: 734.878.0678 pinckney@mainstreetoptometry.com