Exam Registration Form

Select your doctor

Patient Status

Name*

Prefix First Last Suffix

Date of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone*

Mobile Phone*

SSN (last 4 digits only!)

Gender*

Female
Male

Marital Status

Who may we thank for referring you?

Employer

Are the RESPONSIBLE person and the PATIENT the same?*

Yes
No

Responsible Person

Relationship to Patient

Responsible Person Name

Responsible Person Date of Birth

Home Address

Street Address Address Line 2 City State ZIP Code

Responsible Person Email*

Responsible Person Phone

Responsible Person Employer Phone

Responsible Person Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

Employer Email

Responsible Person SSN (last 4 digits only!)

Insurance Coverage Pre-Approval

Do we accept your insurance? Most Likely ...but we still have to process it. Depending on your insurance provider, this process can be time consuming while we try to get the approval necessary for us to proceed with your eyecare plan. Sometimes we find out that your insurance company may have a problem with your coverage that we can correct for you, before you even enter our office! By completing this form on-line, we can take the guess work out of the claim process for you and do all the processing work. We truly want to make your visit to our office a pleasant visit, so our experienced staff will go to work on getting the best coverage possible that you are entitled to by your insurance carrier.

Many times we find situations where your medical insurance and your vision insurance can be applied in conjunction with each other to better cover your needs, so if you have medical insurance please enter your medical insurance carrier information below.

Does the patient have Medical Insurance?

Yes
No

Does the patient have Secondary Medical Insurance?

Yes
No

Does the patient have Vision Insurance?

Yes
No

Primary Medical Insurance

Primary Medical Insurance Company

ID Number

Insured's Relationship to Patient

Insured's Name

First Last

Birth date of Insured

Insured's Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insured's Phone

Insured's Email

SSN of Insured (last 4 digits)

Secondary Medical Insurance

Secondary Medical Insurance Company

ID Number

Insured's Relation to Patient

Insured's Name

First Last

Birth date of Insured

Insured's Street Address

Street Address Address Line 2 City State ZIP Code

Insured's Phone

Insured's Email

SSN of Insured (last 4 digits)

Vision Insurance

Vision Insurance Company*

ID Number

Insured's Relationship to Patient

Insured's Name

Birth date of Insured

Insured's Street Address

Street Address Address Line 2 City State ZIP Code

Insured's Phone

Insured's Email

SSN of Insured (last 4 digits)

Comments

Other information you feel is important

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Email

This field is for validation purposes and should be left unchanged.

Responsible Person

Insurance Coverage Pre-Approval

Primary Medical Insurance

Secondary Medical Insurance

Vision Insurance

Comments

Privacy Policy

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