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Home » Contact Us » Patient Registration Form

Patient Registration Form

Please complete the information below and submit the form 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.

As required under Michigan Executive Order 2020-21, our office will be closed through April 13, 2020.  If you have ordered contact lenses or eyeglasses, we will make arrangements with you to have your order sent directly to your residence.  If you have less than a two-month supply of contact lenses, please contact us and we will be happy to place an order for you. 

If you have any questions about an order, or are experiencing an eye care emergency, please call our office or text message us at 734-414-1892 or email us at reception@progressivefamilyeyecare.com.  

If you would like to schedule an appointment for a date after April 14, 2020, please contact us and leave a message and we will reply to schedule the appointment.  Together we will weather this storm.  Thank you for your continued support and stay safe, https://www.michigan.gov/whitmer/0,9309,7-387-90499_90705-522626--,00.html