Patient Registration- Littzi Eye Care
Appointment Time:
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Hour
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50
Minutes
AM
PM
AM/PM Option
Appointment Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
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Washington
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State
Zip Code
Birth Date
*
Please select a month
January
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Month
Please select a day
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31
Day
Please select a year
2026
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1927
1926
1925
1924
1923
1922
1921
1920
Year
Email Address (Where you want your bills sent)
*
Cell Phone
*
Home/Alternate Phone (We like to have an alternate phone number if the doctor wants to contact you in emergency. Write None if no alternate phone)
*
Work Phone
*
Preferred Method of Contact
Please Select
E Mail
Cell Phone Voice
Cell Phone Text
Work Phone
Home Phone
Social Security Number
Status
Single
Married
Divorced
Widowed
Employment
Employed
Unemployed
Disabled
Retired
Student
Current Employer (Enter None if no employer)
*
Current University/College
Primary Care Provider
*
How did you find our office?
*
Preferred Pharmacy
*
Preferred Pharmacy Phone
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone - Write None if inapplicable
*
Work Phone
*
Cell Phone
*
Relationship to the patient
*
Insurance Information
Primary Insurance Company
*
Member Name on Insurance Card
*
Member ID
*
Upload both sides of Insurance Card
Browse Files
Cancel
of
Secondary Insurance Company
Member Name on Secondary Insurance Card
Member ID
Upload both sides of Insurance Card
Browse Files
Cancel
of
Person Responsible For the Bill
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Initials
*
Signature
*
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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