new patient registration

new patient registration

new patient registration

new patient registration

new patient registration

Sex *

If patient is a child please list parent/guardian name

Address (please specify if apartment number) *

Emergency Contact name, phone number and relation:

Are you interested in using contact lenses? *

We offer a variety of frame styles in our eyewear boutique. Would you like to see the frames at the time of your visit? Our frame stylist will guide you with your frame selection based to best fit your needs. *


​​​​​​​FINANCIAL POLICY STATEMENT

Thank you for choosing our practice for your medical care. We are committed to providing you with the highest quality services available. Please read and sign the following policy. If we are contracted with your insurance company, we will accept assignment. All co-pays, co-insurance and deductibles are due and payable at time of service. Failure to provide necessary referrals or current accurate billing information will result in all charges for services the sole responsibility of the patient/responsible party. You will be responsible for any balances not covered by your insurance. A return check fee of $35.00 will be assessed if your check is returned by your bank. Our cancellation and “no show” policy is as follows: First occurrence, patient will be charged a $25.00 fee. Second occurrence, patient will be charged a $35 fee. Third occurrence, patient will be charged a $50 fee. The patient may be charged the full price of the scheduled office visit for any additional “no show” or any appointment cancellation that occurs within 24 hours of a scheduled appointment.
HIPAA - This office will comply with all aspects as printed in our Notice of Privacy Practice, and our privacy notice will be in compliance with all appropriate laws and regulations.

I agree to the financial policy statement. *

Please list any medications you are currently taking:

List all Allergies:

Please provide your Primary Care Physician name and address *

Please list your pharmacy information:

How did you hear about us: (i.e friend, family, social media, google)

How do you want to pay?

Please upload insurance card