Topa Topa Optometry Patient Registration

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • We are happy to see you for your visit today. We would like to inform you that without the proper insurance information, we cannot verify that your fees will be paid for by insurance. The entire balance will be your financial responsibility.
    I certify that I, and/or my dependent(s) have insurance coverage that I presented and assign directly to Drs. Brockman & Tsao all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. I authorize the disclosure of my health care information as needed to process these claims.
  • We can photocopy a list of your medications or obtain a list from your physician if you prefer:

  • Person to contact in case of emergency: