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Outside photograph of Crystal Eyes Vision Center

Save time by downloading our registration and standard office forms before your appointment. Links to these forms are provided below in PDF and MicroSoft® Word formats.

Download Entire Patient Packet (.pdf)
Download Entire Patient Packet (.doc)

Patient Information Form (.pdf)
Patient Information Form (.doc)

Vision Insurance & Patient Responsibility (.pdf)
Vision Insurance & Patient Responsibility (.doc)

Medical Insurance & Patient Responsibility (.pdf)
Medical Insurance & Patient Responsibility (.doc)

Our Mission (.pdf)
Our Mission (.doc)

HIPAA Privacy Notice for CEVC (.pdf)
HIPAA Privacy Notice for CEVC (.doc)

Eyewear Lifestyle Questionnaire (.pdf)
Eyewear Lifestyle Questionnaire (.doc)

Dry Eye Questionnaire (.pdf)
Dry Eye Questionnaire (.doc)

Cancellation & No Show Policy (.pdf)
Cancellation & No Show Policy (.doc)


Welcome to our Practice Forms

Please fill out the form below so that we may make an appointment for you. You may email the form directly to our staff with the "Submit Form" link at the bottom of the form. This process will allow us to better serve you. THANK YOU!














Routine Exam
Contact Lens
Medical Exam

Monday Tuesday     Wednesday
Thursday     Friday


9:00 am - Noon
2:00 pm - 5:00 pm





Please note, our office REQUIRES at least 24 hour notice if you are unable to make it to your scheduled appointment. Failure to show up for an appointment, or cancellation less than 24 hours from the scheduled time, will result in a $25 office charge. This fee will be assessed to you, and will be forwarded to collections if not paid within 14 days.

We apologize for any inconvenience this may cause you. However, in order to operate our office in an efficient manner, we are forced to follow this rule very strictly.



©2013 Crystal Eyes Vision Center   |   1164 Lexington Avenue   |   Mansfield, Ohio 44907   |   appts@cevc.net