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

     

    Be sure to fill out your Medical Vision/History form. Click Here once you have submitted this form to be redirected.