Online Patient Registration - save time by registering online with Eye Care Center Optometrists!

Eye Care Center Optometrists
Online Patient Registration

Thank you for choosing Eye Care Center for your eye care services. Please take the time to complete this questionnaire accurately and completely. It helps us do the best job possible for you. This information is held in complete confidence as it is part of your permanent record, and will not be released to anyone unless you authorize its release in writing.

Fields marked with an asterisk (*) are required.

Please select the Eye Care Center office you plan to visit.

* Which office do you plan to visit?:

How did you hear about us?:

Patient Information ______________________________________

* Last Name:

* First Name:

Middle Name:

SSN:

Address:

City:

State:

Zip Code:

* Date of Birth:

Select Date

* Primary Phone #:

Please enter patient's secondary phone number. ex: 859-623-5555

Other Phone #:

Email Address:

Sex:
FemaleMale

Student Status:

Marital Status:

Employment Status:

Employer:

Employer Phone:

Emergency Contact (Not living with you):

Emergency Contact Phone #:

Responsible Party Information ______________________________

Patients under 18 years of age may not be their own Responsible Party.

Is the patient also the Responsible Party?

* Is patient also the Responsible Party?:
YesNo

Insurance Information _____________________________________

We require all insurance information prior to services being provided. Due to the diverse nature of many eye conditions, disorders, and procedures, many of the services we provide are covered by your MAJOR MEDICAL INSURANCE rather than routine vision coverage. Please provide us with all of your insurance policy information even if you believe that you are seeing us for a non-medical reason.

Please select the number of policies that cover the patient.

* How many insurance policies cover the patient?:
None1234

Eye Care Center Policies ___________________________________

Please read and sign below

Contact lenses: If you are a contact lens wearer, there will be an additional charge to your exam for a contact lens evaluation. This fee includes lens selection, evaluation of the lens on the eye, any training required, lens changes if required, and all contact lens related follow up visits. The level of the evaluation fee assessed is based upon the type of contact lenses you wear and the complexity of your prescription.

Financial: Full Payment is due at the time of service. Cash, checks, and credit cards are accepted. All refunds or exchanges of material must be done within 30 days of purchase. There are no refunds for any professional services. There is a $20 fee for returned checks. Any refund due to you of $5.00 or less will be credited to your account.

Insurance: All co-pays and deductibles are due at the time of service. Please be aware that some, and perhaps all, of the services provided may not be covered. The balance is the responsibility of the patient whether the insurance pays or not.

Privacy Statement: The information you provide in completing this form will be used by the Eye Care Center to properly register the patient in our system. It will not be sold to any other parties.

Minor Patients: In providing this registration I attest that I am a legal guardian of this minor and have full parental rights to have the minor treated at this facility.

By typing your full name below, you authorize the release of any medical information to process this and any further claims. You further authorize assignment of all medical benefits to the Eye Care Center.

* Signature:

* Date:

Select Date