Farallon Eye Physicians (Susan Longar) - New Patient Registration

New Patient Registration

Susan Longar, M.D., Ting Ting Liu, M.D., Daniel Buckley, M.D., and Peter Martindale, O.D.
Name*

First NameMiddle NameLast Name
Gender*
Race or Ethnicity*
Primary Language*
Age*
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primacy Care Doctor*

First NameLast Name
Primary Care Phone Number*
Please enter a valid phone number.
Employer*
Occupation*
Have you been referred by your Primary Care Doctor or another doctor?*

YesNo
Emergency Contact*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.

Vision Plan Insurance
Company
Name of Subscriber

First NameLast Name
Relationship to Subscriber

SelfSpouseParentOther
Vision Plan (VSP or MES)
Member ID
Last four numbers of SSN
Medical Insurance
Company
Name of Subscriber

First NameLast Name
Relationship to Subscriber

SelfSpouseParentOther
Member ID
Group Name (HMO)
Last four numbers of SSN
By signing below, I authorize my insurance benefits to be paid directly to the doctor and agree that I will be responsible for any non-covered services. I authorize my physician(s) and/or their agents to release any information to my insurance company to process claims for my care.*

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New Patient Registration