Eye See Optometry

Contact Information

Name*

First Last

Phone*

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Guardian Information

(if patient is under 18 years of age)

Name

First Last

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Patient Information

Gender*

Date of Birth*

Social Security Number*

Primary Insurance information

Provider Name

Provider Phone

Provider/I.D. No.

Group No.

Secondary Insurance information

Provider Name

Provider Phone

Provider/I.D. No.

Group No.

Additional Insurance information

Provider Name

Provider Phone

Provider/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 the NPP & I wish to continue my care under said terms.
No, I have not read this office’s NPP but I was given the opportunity to read it and declined. I wish to continue my care under said terms.
The NPP could not be read due to the emergent nature of the care needed.

Signature agreeing to all above terms

Date