Welcome to Our Office
Welcome to Enhanced Eye Care. Thank you for choosing us for your eyecare needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information.
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Mr.
Mrs.
Miss
Ms.
Name
First Name
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Last Name
Preferred Name
Street Address
City
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Male
Male
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Social Security Number
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Month
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Day
Year
Date
Home Phone Include Area Code
Cell Phone
Email Address
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Person Responsible for Account
Emergency Contact
Emergency Phone
Medical Insurance Company
Vision Insurance Company Name
Primary Care Physician and Clinic Name
Primary Care Physician Street Address
City - Primary Care Physician
State - Primary Care Physician
Zip Code - Primary Care Physician
Phone - Primary Care Physician
Referring Phvsician and Clinic Name
Address of Referring Physician
City
State
Zip
Phone
Race
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Hispanic Or Latino
Asian
Native Hawaiian Or Other Pacific Islander
Black Or African American
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Ethnicity
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Height (FT)
Height (Inches)
Weight
Preferred Language
English
Chinese
Dutch; Flemish
French
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Hind
How were you referred to our office?
Phone Book
School
Advertisement
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