Home » Patient Paperwork Patient Paperwork Name(Required) First Middle Last Date Of Birth(Required) MM slash DD slash YYYY Social Security NumberEnter the last 4 digitsHow'd You Hear About Us?(Required)Please selectOnlineFriend/FamilyDoctor ReferredMailMagazineOtherMarital Status(Required)Please selectSingleMarriedSeparatedDivorcedWidowedParent/Guardian Name (for patients under 18 years of age) First Last Email(Required) Cell Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date(Required) MM slash DD slash YYYY Preferred Language(Required)Emergency Contact(Required) First Middle Last Emergency Contact Cell Phone(Required)Race(Required) Caucasian Asian Black/African American American Indian/Alaska Native Native Hawaiian or Other Pacific Islander Hispanic Other Decline Ethnicity(Required) Not Hispanic/Latino Hispanic/Latino Decline Primary Medical Insurance Name(Required)Member ID Number(Required)Insurance Subscriber Name(Required) First Middle Last Insurance Subscriber Date of Birth(Required) MM slash DD slash YYYY Relation to Patient(Required)Secondary Insurance NameSecondary Insurance Member ID NumberVision Insurance NameVision Insurance Member ID NumberPerson authorized to receive/discuss medical and/or financial information*(Required) First Middle Last I understand that:(Required) Most medical insurance plans, including Medicare, do not cover routine refraction or routine eye examinations Our office fee for a refraction is $80.00 and this is collected at the time of service, in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly. Vision Plans:(Required) It is the patient’s responsibility to know if he/she has a vision plan AND what company it is with. Managed Health Care Plans:(Required) If the patient does not have vision coverage, or is not eligible for a vision exam, then the patient is responsible for a referral from the primary care physician. If a referral is not received at the time of service, the patient will be financially responsible for all the care and services rendered at the time of service. Payment:(Required) The patient is responsible for all charges, deductible payments, co-insurance and/or co-pay payments at the time of service. Cancellations and Missed Appointmentst:(Required) The patient is responsible for giving at least a 24 hour notice of any cancellation of his/her appointment. ALL MISSED APPOINTMENTS WILL BE CHARGED $50. Consent:(Required) I have read and understood the above office policies. I agree that I am financially responsible for any and all care that is not covered by my insurance policy. Signature(Required)Comments Δ
