Home 9 Patient Resources 9 Contact 9 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.

  • Patient Information

  • Please provide a telephone number, with area code, so we can contact you.
  • Please provide us your email address.
  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Eye History

  • Glasses History

  • Contact Lens History

  • Medical History

  • Primary Insurance

  • Please bring all insurance cards with you to your appointment.

  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • Comments

  • Privacy Policy

Schedule an Appointment
Patient History Form
InfantSEE® Form
Contact Form
Testimonials

first rate

Caring and prompt, the service is always first rate.
Patient in Warrensburg MO

I wish all doctors were modeled after him

I see Dr. Kyle Johnson and he is awesome. He takes the time to answer all of my questions and concerns and I believe he truly cares. I have never seen him without a smile and kind, compassionate, positive attitude. I wish all doctors were modeled after him. You won’t be sorry, if you choose to see him. The office staff are all very polite, professional, and efficient.
Patient In Clinton, MO

I see a lot of doctors, but Dr.Susan is the only one I look forward to seeing each year

Everyone in the office is extremely nice. I am 72 yrs. old and a long time patient with only one good eye. I trust Dr. Susan Lake with the care of it 100%. Being 72, I see a lot of doctors, but Dr.Susan is the only one I look forward to seeing each year.
Patient in Warrensburg MO

I highly recommend them

I’ve been going to Dr. Liesemeyer for almost 25 years. His group offers personal and professional services I highly recommend them.
Patient In Sedalia, MO