Creative Optical > New Patients > Adult patient registration

First Name:

Last Name:

Email Address:

Company Name:

Street:

City:

Region:

Postal Code:

Telephone:

Cellular Phone:

Work phone:

How did you hear about us?:

Marital Status:

Single / Divorced
Married / Domestic Parnter

Race/Ethnicity:

PATIENT INFORMATION:

SSN:

Age:

Sex:

Male
Female

P.O. Box Address:

Home Phone:

TEMPORARY WINTER ADDRESS:

Employer:

Employer Phone Number:

Marital Status:

Single
Married
Divorced

Employer Phone Number:

VISION INSURANCE INFORMATION:

Is this Patient covered by vision insurance?:

Yes
No

Insurance:

Policy Number:

Group Number:

Co-pay:

Subscriber’s Name:

Subscriber’s SSN:

Birth Date:

Patient relationship to subscriber:

Spouse
Dependant
Other

Please indicate other medical insurance (list on back if needed):

Insurance:

Policy Number:

Group Number:

Co-pay:

Subscriber’s Name:

Subscriber’s SSN:

Birth Date:

Patient relationship to subscriber:

Spouse
Dependant
Other

Name of local friend or relative(not living at same address):

Relationship to Patient:

Home Phone:

Work Phone:

Referred to clinic by :

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 Creative Optical or insurance company to release any information required to process my claims.

_________________________________________________ ______________________
Patient/Guardian signature Date