sohieyecare.com - NEW PATIENT REGISTRATION

NEW PATIENT REGISTRATION
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

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suite/Apt.
Daytime Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Guardian Information (if patient is under 18 years of age)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suite/Apt.
Daytime Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Patient Information
Gender
Date of Birth

MonthDayYear
Date
Social Security No.
Primary Insurance Information
Provider Name
Provider Phone
Please enter a valid phone number.
Policy/I.D. No.
Group No.
Secondary Insurance Information
Provider Name
Provider Phone
Please enter a valid phone number.
Policy/I.D. No.
Group No.
Additional Insurance Information
Provider Name
Provider Phone
Please enter a valid phone number.
Policy/I.D. No.
Group No.
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)

Yes, I have read or had explained to me by this office theNPP & I wish to continue my care under said terms.No, I have not read this office’s NPP but I was given theopportunity to read it and declined. I wish to continue mycare under said termsThe NPP could not be read due to the emergent nature ofthe care needed.
Signature agreeing to all above terms

Clear
Date

MonthDayYear
Date