New Patient Registration Form 2024/2025

Patient Information Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone Number*
Please enter a valid phone number.
Is this your... ?

CellHome Phone
Alternate Phone Number
Please enter a valid phone number.
Is this your... ?

CellHome Phone
Are you are interested in a contact lens exam?*

YesNo
If yes, have you worn contact lenses before?*

YesNo
Last 4 digits of your Social Security Number
Your social security number is used for insurance purposes only. If you do not provide this information we may not be able to verify or submit to your insurance company
What is your occupation?
How did you hear about us?*

Friend/FamilyFacebook/Social MediaInsuranceDriveby/LocationInternet/WebsiteOther
INSURANCE INFORMATION
Please bring all of your insurance information and cards to our office on the day of your appointment.
Name of Medical Insurance
Policy Number
Policy Holder Name (if different)
Policy Holder Date of Birth (if different)

MonthDayYear
Date
Policy Holder Social Security # (if different)
Choose File

Choose file upload maximum file size allowed: 10mb
Cancelof
Or
Take Photo
Do you have Vision Insurance?

YesNo
Vision Insurance Name
Vision Insurance Policy Number
Health Information
Type a question
Type a question
Who is your Family Physician?
Address
What is the reason for your upcoming visit?
PATIENT FINANCIAL RESPONSIBILITY*

I am authorizing the release of medical and other necessary information to process insurance claims, and where applicable, also request payment of government benefits to the party who accepts assignment. Hitting "Submit" authorizes the payment of medical benefits to the physician or supplier for services rendered. Click here for the complete terms and conditions or visit our website. Please check that you understand Patient Financial Responsibility.
HIPAA PATIENT PRIVACY PRACTICES*

We are required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices with respect to such information and to abide by the terms of this Notice. Click here for the complete HIPAA Privacy Practices or visit our website. Please check that you understand our HIPAA Privacy Practices.
CONTACT LENS AND EYEGLASS PRESCRIPTION ACKNOWLEDGEMENT*

In accordance with the Federal Trade Commission (FTC) regulations under the fairness to Contact Lens Consumer Act of 2020 and Eyeglass Rule of 2024, consumers are entitled to receive their contact lens and eyeglass prescriptions at the completion of their exam. All prescriptions for contact lenses and eyeglasses are provided through our patient portal. I acknowledge that I will have access to these prescriptions through the patient portal. Portal access is available at Yardleyeyecare.com Paper copies will also be provided upon request.
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Patient Information Form

Health Information