Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

First Visit?

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Name:*

Prefix First Last Suffix

Date of Birth:*

MM

DD

YYYY

SS#:

Race:

Preferred Language:

Address:*

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

Phone:*

Email:

Place of Employment/School:

Occupation:

How did you hear about us?

Insurance/Guarantor Information

Name:

First Last

Relationship:

Date of Birth:

MM

DD

YYYY

SS#

Employer:

Work Phone:

Health Insurance Co.:

Policy Number

Vision Insurance Co.:

Policy Number

In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery to do so. If applicable, I hereby authorize that payment by my insurance company be made directly to Optic Gallery for any services rendered to me. I also authorize Optic Gallery to release any information that is required to process a claim for services rendered.

I UNDERSTAND THAT I AM RESPONSIBLE FOR CHARGES NOT COVERED BY MY INSURANCE COMPANY

Signature (Patient/Guardian):*

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Patient Information & Insurance

Patient Information

Insurance/Guarantor Information

Optic Gallery Family Eye Care