Patient

Name*

First Middle Initial Last

Nickname

Gender

Male
Female

Student

Yes
No

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number

Age

Date of Birth*

What is the best way to reach you by phone?*

Home phone
Cell phone

Home Phone*

Cell Phone*

Work Phone

E-mail Address*

I am interested in being registered for online contact lens orders:

Yes (e-mail required above)
No

I am interested in receiving e-mail promotions for savings on glasses and/or contacts

Yes
No

Marital Status

Single
Married
Divorced
Widowed

Employment

Full-Time
Part-Time
Retired
Unemployed

Name of Employer/Occupation

Address of Employer

Is patient covered by another group vision plan?

Yes
No

If "yes", complete the following:

Vision Plan Name

Union Local

Group #

Name and Address of Carrier

Was an accident involved?

Yes
No

If "yes", was the injured person at work when the accident happened?

Yes
No

Has cataract surgery been performed?

Yes
No

If yes:

Left Eye - Date of Surgery

Doctor

Right Eye - Date of Surgery

Doctor

Falsification or misrepresentation of information requested below may result in action(s) deemed appropriate by Employer and/or insurance. (Please answer all questions before claim is completed.)

Patient's Relationship to Insurance Enrollee*

Self
Spouse
Dependent/Child

Name of Insured

Name

First Middle Initial Last

Social Security Number

Address

Street Address Address Line 2 City State ZIP Code

Age

Date of Birth

Gender

Male
Female

Name of Employer

Address of Employer

Authorization

I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for services to the physician OR organization furnishing the services and authorize such physician OR organization to submit a claim to my insurance carrier OR Medicare for payment. I authorize any holder of medical or other information about me to release to insurance carriers OR the Health Care Financing Administration and its agents OR the Social Security Administration or its intermediaries OR any agency, group or person(s) necessary to secure payment any information needed for this or related Medicare claim. *For and in consideration of services rendered and to be rendered by the above listed medical provider, I hereby guarantee payment of all charges incurred for this account. *The patient or his/her representative recognizing the need for health care, consents to the above listed medical provider rendering services as ordered by the physicians, including medical or surgical treatment, laboratory procedures, X-ray examinations or other services rendered under the general and specific instructions of the physicians. *I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct.

Date

Signature of Patient (Parent/Guardian if minor)

Patient Registration Form

Patient

Name of Insured

Authorization

Past Medical History and Review of Symptoms

Past Eye History and Surgery

Social History

Request Appointment

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%	Eye (R/L)	Times Daily