SVS Vision – Patient Exam Form – Patient Registration Forms

Please be aware that the form below is for patients who have an upcoming appointment scheduled. If you do not have an appointment scheduled at this time and you would like to schedule one, please visit svsvision.com/contact or give your local office a call directly.
Date of Appointment*
MM slash DD slash YYYY
Patient Name:*
First Last
DOB:*
Patient Address:*
Street Address Address Line 2 / Apt Number / Suite City State ZIP Code
Phone:*
Cell:
Email:*
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:*
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*
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*
MM slash DD slash YYYY
Signature of Patient’s Representative:*
Date*
MM slash DD slash YYYY
Name of Patient’s Representative:
First Name Last Name
Relationship:

Please answer if you or your family members (grandparents, parents, or siblings) have any of the following medical conditions.