La Paz Optometric – Established Patients – Patient Registration Forms

Welcome Back To Our Office

Name

First Last

Date

Address

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

Phone Number

Cell Phone Number

Email

Has your medical insurance changed?

New Medical insurance (P.P.O H.M.O)

Have there been any changes in the following categories since your last visit?

If yes, please explain:

Please check the box if any of the following are true: