Vision Insurance


  


Our primary objective is to provide the best eye health care to every patient that enters our office. In order to accomplish this goal we must require every patient to provide detailed information regarding medical history, all insurance plans, optical coverages or discount plans that apply to each visit. Please complete all areas of this registration form.

Name:

Appointment Date (mm/dd/yy):

Complete Address:

Home & Work Phone #'s:
Social Security #:
Employer & Occupation:
Date of Birth (mm/dd/yy):
E-Mail Address:
Primary Insurance Carrier:
Member ID #:
Name of Subscriber:
Relationship to Patient:
Plan Name or #:
Secondary Insurance Carrier:
Member ID #:
Name of Subscriber:
Relationship to Patient:
Plan Name or #:
Do you or your blood relatives have a history of any of the following? (select all that apply)
Specify any other eye or health problems:
Have you had eye surgery?
Have you had an eye injury?
List type & date of eye surgery or injury:
Do you use any of the following? (select all that apply)
List current medications:
List Allergies:
Family doctor name/address/phone#:
Select office location for this visit:
By hitting the 'Submit' button below, I acknowledge that the information given above is complete and correct. I agree that any charges not covered by my insurance coverage(s) will be paid in full at the time of delivery of services or goods. I understand that if I do not provide accurate insurance coverage information prior to services I am responsible for submitting any claims to my insurance carrier (regardless of provider participation).

Payment of insurance copays & exam/fitting fees are due on date of service.

Minimum deposit of 50% required to order any eyewear or contact lenses.

Vision Insurance