Creative Optical > New Patients > 2011 Minor Registration Form

First Name:

Last Name:

Date:

Select Date

Primary Care Physician:

PATIENT INFORMATION:

Middle:

Birth Date:

Age:

SSN:

Sex:

Male
Female

Street Address:

City:

State:

Zip:

P.O. Box Address:

Home Phone:

PARENT/LEGAL GUARDIAN INFORMATION:

Parent/Legal Guardian Last Name:

First Name:

Middle:

Birth Date:

Age:

SSN:

Home Phone:

Street Address:

City:

State:

Zip:

P.O. Box Address:

E-Mail:

Cell Phone:

Occupation:

Employer:

Work Phone:

Parent/Legal Guardian Last Name:

First Name:

Middle:

Birth Date:

Age:

SSN:

Home Ph:

Street Address:

City:

State:

Zip:

P.O. Box Address:

E-Mail:

Cell Ph:

Occupation:

Employer:

Work Ph:

MEDICAL INSURANCE INFORMATION:

Is this patient covered by medical insurance? :

Yes
No

Insurance:

Policy Number:

Group Number:

Co-pay:

Subscriber’s Name:

Subscriber’s SSN:

Birth Date:

Patient relationship to subscriber:

Dependant
Other

IN CASE OF EMERGENCY:

Name of local friend or relative: :

Relationship to Patient:

Home Ph:

Work Ph:

Referred to clinic by (Please check one box):

Doctor
Family
Friend
Yellow pages
Other

Other family members seen here:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Jefferson Eye Surgeons or insurance company to release any information required to process my claims.

Parent / Legal Guardian signature:

Date: