New Patient Registration 2024

New Patient Registration
Name*

Last NameFirst Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState

Postal Code
Preferred Phone Number*
Please enter a valid phone number.
Is this your... ?

Cell PhoneHome Phone
Alternate Phone Number
Please enter a valid phone number.
Is this your... ?

Cell PhoneHome Phone
Are you are interested in a contact lens exam?*

YesNo
If yes, have you worn contact lenses before?*

YesNo
Last 4 digits of your Social Security Number
Your social security number is used for insurance purposes only. If you do not provide this information we may not be able to verify or submit to your insurance company
What is your occupation?
How did you hear about us?*

Friend/FamilyDrive by/LocationFacebook/Social MediaInternet/WebsiteInsuranceOther
INSURANCE INFORMATION

Please bring all of your insurance information and cards to our office on the day of your appointment.
Name of Medical Insurance
Policy Number
Policy Holder Name (if different)

First NameLast Name
Policy Holder Date of Birth (if different)

MonthDayYear
Date
Policy Holder Social Security # (if different)
Choose File

Choose file upload maximum file size allowed: 10mb
Cancelof
Or
Take Photo
Do you have Vision Insurance

YesNo
Vision Insurance Name
Vision Insurance Policy Number
HEALTH INFORMATION
Who is your Family Physician?
City
What is the reason for your upcoming visit?
PATIENT FINANCIAL RESPONSIBILITY*
HIPAA PATIENT PRIVACY PRACTICES*
CONTACT LENS AND EYEGLASS PRESCRIPTION ACKNOWLEDGEMENT*
Should be Empty:

New Patient Registration

INSURANCE INFORMATION

Or

HEALTH INFORMATION