4911 LC Eye Clinic

Patient Information

Date

Name*

Prefix First Middle Last

How do you wish to be addressed?

Patient's Date of Birth*

Sex

Patient's Address*

Street Address Address Line 2 City State ZIP Code

Patient's Phone Number(s)*

Cell	Home	Work

Preferred Number

Social Security Number

Is Patient*

Please list

Grade	School	Teacher

Occupation

Please list Employer(s)

Name of Emergency Contact or Legal Guardian*

First Last

I currently wear

Select All
Glasses
Contacts

Who Prescribed?

Who may we thank for referring you to us?

Insurance Information

We gladly accept the following Insurance plans(please check if applicable)

Regence or BC/BS
Medicare
Medicare Supplement
Group Health
Community Health Plan
First Choice
DSHS
Premera
Tricare

Name of Subscriber

Subscriber I.D. No.

If your insurance is not listed above, we would ask that payment be made when services are rendered. We will provide an insurance bill that you can send in to your insurance company for reimbursement.*

I accept

I understand that I am responsible for payment of any charges not covered by my insurance. I authorize payment of healthcare benefits to this clinic. I also authorize release of any medical records necessary to process any claims.

Full payment for services, glasses and contacts is due when received. Thank You.*

Signature of Patient/ Guardian