Click here to download a printable version if you prefer not to submit your information online Patient Name First Name: Middle Name: Last Name: Sex: ---FM Physical Address Street 1: Street 2: City: State: Zip: Billing Address Same as Physical Address: ---YesNo Billing Address Street 1: Street 2: City: State: Zip: Next Contact Information How did you hear about us? Referred By Home Number: Work Number: Cell Number: Email: Preferred Contact: ---Home PhoneCell PhoneWork PhoneTextEmail BackNext Work Information Employer: Occupation: Social Security Number: Date of Birth Doctor Information Patient's Medical Doctor: City: Parent / Spouse Information Marital Status singlemarried Responsible Party: ---SelfSpouseParent Parent / Spouse Name: Parent / Spouse DOB Parent / Spouse SSN: Parent / Spouse Employer: BackNext Vision Insurance Information Have Vision Insurance: ---YesNo Vision Insurance: Subscriber's Name: Subscriber's ID: Subscribers Birth Date Medical Insurance Information Have Medical Insurance: ---YesNo Primary Medical Insurance: Secondary Medical Insurance: Subscriber's Name: Subscriber's ID: Subscribers Birth Date We are a participating member of Medicare and our office accepts most vision and medical insurance plans. If you are insured by a plan that we do not participate in, please let us know and we will do our best to offer you the same benefits. I authorize this office to release any information needed to process any insurance claim. I understand that I am responsible for any charges regardless of insurance coverage. BackNext Pharmacy Information Pharmacy Name: Pharmacy Address: Pharmacy Number: Name of Responsible Party: Date Click here to view the HIPAA Notice of Privacy Policies document By signing this, you are agreeing to the HIPAA Notice of Privacy Policies document at the link above. Be sure to fill out your Medical Vision/History form. Click Here once you have submitted this form to be redirected. Developed and Hosted by BIG Copyright 2018© All Rights Reserved Forgot password? Remember me You can login using your social profile Problem with login?