Patient Information & Insurance

Name: Optic Gallery Family Eye Care
Address: 4036 River Oaks Dr, Ste B-8, Myrtle Beach, SC, 29579, US
Telephone: 843-236-2500
Price range: $000 - $300

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?
- Yes
- No
Name:*
Prefix First Last Suffix
Date of Birth:*
Month
Day
Year
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:
Month
Day
Year
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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Phone
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Patient Information

Insurance/Guarantor Information

Optic Gallery Family Eye Care