The Eye Center of Parkville Patient Form

Welcome to The Eye Center of Parkville
Patient Registration

Please fill in the information below
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Sex*
Marital Status*
Occupation:*
Cell Phone Number*
E-mail*
In case of emergency...
Emergency Contact:*

First NameLast Name
Relationship to Patient*
Contact Number*
Billing Information
Primary Insurance Policy Holder*

First NameLast Name
Date of Birth*

MonthDayYear
Relationship to Patient*
Please Complete For Minors

(under the age of 18)
Financially Responsible Party Name

First NameLast Name
Financially Responsible Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I consent to a detailed message left on voicemail:*
I would like to receive my appointment reminders by: *
I understand and acknowlege the following:
- The Eye Center of Parkville follows HIPAA laws that protect your personal health information. I have been offered a copy of the Notice of Privacy Practices (HIPAA).
- I authorize The Eye Center of Parkville to bill my insurance company and receive payments.
- I understand I am financially responsible for all copays, deductibles and coinsurance amounts.
- I also authorize The Eye Center of Parkville to release any information needed for the processing of my claim.
- I understand that payment for all optometric professional services is due at the time of service.
- I understand that payment for eye glasses and contact lenses is due at the time of ordering.
Signature*

Clear
Please click "Next" to continue completing the form
Thank you for completing the information above. We look forward to seeing you for your appointment!
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Welcome to The Eye Center of Parkville

Patient Registration

Billing Information

Please Complete For Minors