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: —Please choose an option—FM Physical Address Street 1: Street 2: City: State: Zip: Billing Address Same as Physical Address: —Please choose an option—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: —Please choose an option—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 Statussinglemarried Responsible Party: —Please choose an option—SelfSpouseParent Parent / Spouse Name: Parent / Spouse DOB Parent / Spouse SSN: Parent / Spouse Employer: BackNext Vision Insurance Information Have Vision Insurance: —Please choose an option—YesNo Vision Insurance: Subscriber's Name: Subscriber's ID: Subscribers Birth Date Medical Insurance Information Have Medical Insurance: —Please choose an option—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 Back Δ Be sure to fill out your Medical Vision/History form. Click Here once you have submitted this form to be redirected.