SVS Vision – Patient Exam Form – Patient Registration Forms

Patient Name:*
First Last
Patient Address:*
Street Address Address Line 2 / Apt Number / Suite City State ZIP Code
DOB:*
Date Format: MM slash DD slash YYYY
Email:*
Phone:*
Cell:
Occupation:
Marital Status*
- Single
- Married
- Divorced
- Widowed
Gender*
- Male
- Female

Insurance Information
Is there a vision insurance you would like to use at the time of your appointment?*
- Yes
- No
Insurance Name:*
Policy Holder Name:*
First Name Last Name
Policy Holder's Date of Birth:*
Date Format: MM slash DD slash YYYY
ID #*
I hereby authorize payment of my insurance benefits to SVS Vision, Inc. for expenses incurred on this date for the above-named patient. I further authorize SVS Vision, Inc. to submit claims and supporting information for goods and procedures indicated below and for equivalent goods and procedures according to my insurance carrier’s guidelines. I understand that SVS Vision, Inc. will verify my insurance and obtain any authorizations necessary. I acknowledge that this is not a guarantee of payment by my insurance carrier, and, unless otherwise prohibited, I am responsible for any and all charges not covered by my insurance plan.
Signature*
Date*
Date Format: MM slash DD slash YYYY

Click Here to Download our Privacy Policy
Receipt of Privacy Policy Notice*
First Name Last Name
I, (Please enter full legal name above), the “Patient” or “Patient’s legal representative” (if the patient is a minor or an adult who is unable to sign this form) have been presented with the Notice of Privacy Policy (the “Policy” of SVS Vision), and have been offered a copy of such policy to keep for my records.
I am the:*
Patient
Patient's Representative
Signature*
Date*
Date Format: MM slash DD slash YYYY
Signature of Patient’s Representative:*
Date*
Date Format: MM slash DD slash YYYY
Name of Patient’s Representative:
First Name Last Name
Relationship:

Please sign below to acknowledge that the information given on this form is current: