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New Patient Registration Form

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In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Contact Information

Name *
*
*
Address *

Patient Information

Date of Birth *

Primary Insurance Information

Secondary Insurance Information

Additional Insurance Information

Guardian Information (if patient is under 18 years of age)

Guardian Name
Guardian Address

Vision Correction History

Please check any that apply

Glasses History

What glasses do you own? (check all that apply)
Glasses concerns (check any that apply)

Contact Lens History

Contact lens concerns (check any that apply)

Family History

Check any that apply

General Medical History

Do you have any of the following?

Referral Information

Why did you visit us?

Financial Assignment & Privacy Acknowledgment

Financial Assignment Information: I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Acknowledgment of Notice of Privacy Practices (NPP) *
*
Date *