Patient Registration Form

Confidential Patient Information

Please fill in the form below
Name:

First Name Middle Name Last Name
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number:

Area Code Phone Number
Cell Phone Number:

Area Code Phone Number
E-mail:
Birth Date

Month Day Year
Sex:

Male Female
Primary Care Physician:
Primary Care Phone Number:

Area Code Phone Number
Your Occupation:
In case of Emergency
Contact:

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship:
INSURANCE INFORMATION
Full Name: (Policy Holder)

First Name Last Name
Birth Date:

Month Day Year
Last 4 of SSN of Policy Holder:
Last 4 of SSN of Policy Holder (if VSP insurance)
Please upload a picture of your insurance card (front and back)

Browse Files

Cancel of
Acknowledgement of understanding of the "Notice of Privacy Practices"

I understand I may ask for a copy of the "Notice of Privacy Practices" for my record and that I otherwise understand the "Notice of Privacy Practices."
Signature

Clear
Insurance Authorization

I hereby assign all payments of benefits to BayState Eye Center to which I am entitled for services rendered. I understand I am financially responsible for the copayment and any non-covered services at the time of service.
Signature

Clear
Date:

Month Day Year Hour Minutes AM/PM Option
Should be Empty:

In case of Emergency