Welcome Back Form

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Preferred Pronouns:   He/Him   She/Her   They/Them                 

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EMERGENCY CONTACT
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 Phone:   Area Code   Phone Number   

MEDICATION CHANGES(if applicable)
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VISION INSURANCE (if applicable)
Insurance Company:    Please Select EyeMed VSP    ID:#      
Primary Insured:   First Name   Last Name   Date of birth:   Date
Relationship to Insured:    Please Select Self Spouse Child Parent Other    

MEDICAL INSURANCE (if applicable)
Insurance Company:    Please Select Anthem Blue Cross/Blue Shield Aetna Aetna Medicare Blue Cross/Blue Shield Medicare Connecticare Connecticare Medicare Cigna Harvard Pilgrim Healthcare Medicare (Traditional) Medicaid United Healthcare United Healthcare/AARP Supplement UMR    ID:#      
Primary Insured:   First Name   Last Name   Date of birth:   Date
Relationship to Insured:    Please Select Self Spouse Child Parent Other    

I have provided any and all insurance information. If any is withheld at time of service, I acknowledge I am responsible for the usual and customary charges for services rendered.

I have read and agree to the Office Policies agreement set by Griswold Eye Care, PLLC.