Patient Registration

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:

Physical Address

Street 1:

Street 2:

City:

State:

Zip:

Billing Address Same as Physical Address:

Billing Address

Street 1:

Street 2:

City:

State:

Zip:

Contact Information

How did you hear about us?

Referred By

Home Number:

Work Number:

Cell Number:

Email:

Preferred Contact:

Work Information

Employer:

Occupation:

Social Security Number:

Date of Birth

Doctor Information

Patient's Medical Doctor:

City:

Parent / Spouse Information

Marital Status

Responsible Party:

Parent / Spouse Name:

Parent / Spouse DOB

Parent / Spouse SSN:

Parent / Spouse Employer:

Vision Insurance Information

Have Vision Insurance:

Vision Insurance:

Subscriber's Name:

Subscriber's ID:

Subscribers Birth Date

Medical Insurance Information

Have Medical Insurance:

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.

Pharmacy Information

Pharmacy Name:

Pharmacy Address:

Pharmacy Number:

Name of Responsible Party:

Date

Click here to view the HIPAA Notice of Privacy Policies document