New Patient Forms

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Patient Information & Insurance

Please provide your personal and insurance details.

Personal Information

First Name*

Last Name*

Date of Birth*

Gender*

Address

Street Address*

City*

State*

Zip Code*

Contact Information

Preferred Phone

Home Phone

Cell Phone

Work Phone

Email Address*

Employment & Emergency Contact

Employer (or School)

Occupation (or Grade)

Emergency Contact*

Emergency Phone*

How Did You Hear About Us?

Referred By

Referral Source

Vision Insurance

Subscriber Name

Subscriber ID#

Subscriber DOB

Primary Medical Insurance

Medical Insurance

Subscriber Name

Subscriber ID#

Subscriber DOB

Assignment of Benefits

I authorize the release of any medical information necessary to process this claim and request payment of medical benefits to be made directly to Eminence Family Eyecare unless payment is made in full at time of service. I agree to bear full responsibility for co-pays, deductibles, non-covered or denied services by my insurance.

Signature*

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Lifestyle Questions

I use digital devices regularlyI think I might benefit from thinner, lighter lensesI prefer NOT to wear glasses at timesI spend time outdoorsI participate in vision-related sports or activities