Welcome Form

Welcome to Eyebright Optometry!

6/15/21 Update per the department of health guidlines our healthcare clinic still requires masks for all individuals.
Date: *

Month Day Year
Date
Miss Mrs. Mr. Dr.
First Name *
Middle Name
Last Name *
Preferred name if different from above
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (*NOTE due to new check in procedures please provide your mobile) *
Alternate Number
Alternate number type

Home Work
Email
example@example.com
Preferred contact method (check all that apply)

Email Mail Phone Text
Employer.
Occupation
Date of birth (patient) *

Month Day Year
Date
Last 4 of SSN *
Vision Insurance
Check all that apply

Davis EyeMed Medicare Superior VSP None Aetna (Eyemed)
If you are NOT the primary member on the plan please provide their information below.
Primary member name
DOB
Primary member last 4 SSN
Relationship to you
Medical Insurance Plan:
Group #
ID#
How did you hear about our office check all that apply

Insurance Listing Patient referral Driving by Office website Doctor Walk-in Google Yelp Social Media
Emergency Contact
Emergency Phone
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) I read the copy of Eyebright Optometry Notice of Privacy (on the office website FORMS page) and understand I may request a copy of records. The Notice of Privacy Practices is subject to change. Update policies will be available at the front desk.
Signature *

Clear
I authorize the payment of health care benefits to this office. I understand I am responsible for payment of any charges not covered by insurance.
Signature *

Clear
I authorize any holder of medical information about me to be released and/ or request my medical information with other health care professionals for the purpose of consultation and referral as needed for my health care.
Signature:

Clear
For the safety of our patients we have new check-in procedures. Please look out for a seperate message with that information.
I have read the new check in procedures on the website. *

Clear
Please print name if signing for a minor.
Name

First Name Last Name
Should be Empty:

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Vision Insurance