Schenker Optometry Patient Reg Form

Step 1 of 3

WELCOME!
We strive to provide the highest level of professional eye care in a friendly and caring environment and to maximize our patients' quality of life; utilize the most advanced technology and professional skills; and inspire confidence through patient education.

Today's Date

Date of Birth(Required)

Age(Required)

Title

Name(Required)

First, Middle, Last

Address(Required)

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

Primary Contact Number(Required)

Type

Secondary Contact Number

Type

Tertiary Contact Number

Type

Email Address(Required)

Spouse or Parent Name

School/Employer

Grade/Occupation

How will you settle your account today?

Cash

Check

Credit

How did you hear of our office?

Referral Name/Others

I consent to the use and disclosure of my health information for the purposes of treatment, payment, and health care operations. In addition, I give my permission for your office to leave telephone messages confirming appointments and any other related office matters.

Signature

Date(Required)

If you are signing as a personal representative of the patient, describe your relationship to the patient.

Relationship to Patient

Print Name

Professional fees are due when services are rendered unless prior arrangements are made. A deposit of 50% is required toward the total cost of glasses before an order can be placed. The remaining balance is due at the time of dispensing. When eyeglasses are purchased through insurance, the balance is due in full when the order is placed. When ordering contact lenses, total payment is due before the order can be placed, unless otherwise specified. Thank you for your cooperation.

[5511] Schenker Optometry