Authorization for Medical Records Release Privacy Practices Refractions

Patient Registration

Patient's Last Name

Patient's First Name

Patient's Middle Name

Social Security #

Date of Birth (MM/DD/YYYY)

Sex

MaleFemale

Address

City

State

ZIP

Race

Language

Home Phone

Day/Cell Phone

Emergency Contact Name

Relationship to Patient

Contact/Alternate Phone

Patient's Employer

Work Phone

Person Responsible for Payment

Relationship

Primary Insurance

Primary Insurance Company

Policyholder Name

Policyholder Date of Birth (MM/DD/YYYY)

ID #

Group #

Relationship to Policy Holder

Secondary Insurance (if applicable)

Secondary Insurance Company

Policyholder Name

Policyholder Date of Birth (MM/DD/YYYY)

ID #

Group #

Relationship to Policy Holder

Patient Portal Access

I would like access to White Eye Associates' secure patient portal where I can: *

Review and verify my contact information

Input medical history / medications / pharmacy information

View handouts

Communicate with staff

Additional Information

Name of Pharmacy

Pharmacy Phone / Location

Name of Primary Care Doctor

Phone

Thank you! Your submission has been received!

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Please bring the following items on your visit:

Insurance Cards(s)
Photo I.D.
Co-Payment (cash, check, credit card)
Your prescription eyeglasses and/or contact lenses
List of medications/eye drops