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Patient Registration Form (Please fill out all areas and then print using the button at the end) - page 1 / 1

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Patient Registration Form (Please fill out all areas and then print using the button at the end)

Name (last)

Address

(first)

(M.I.)

Age

01 DOB (M / D / Y)

City

State

sex Sex

Zip

Work (Daytime) Phone Number

Home (or other) Phone Number

Social Security #

Patient’s Employer (or school)

Name

Employer

Daytime Phone

Date of Birth

SS#

Father or Guardian Mother

Emergency Contact Was condition related to employment?

Daytime Phone

Relationship to Patient

Y

N

(If yes, please ask receptionist for an accident form to complete)

Auto Accident?

Y

N

Who were you referred by:

Phone Book

Other accident? Yellow Pages

YN Newspaper Ad

TV/Radio

Friend

Relative

Physician / Physician’s name:

INSURANCE AND BILLING INFORMATION

Medicare Number Primary Insurance

Medicaid Number

PolicyHolder’s Name

Date of Birth

SSN

Address (if different from Above)

City

State

Zip

PolicyHolder’s Employer

Location

Phone

Patient’s relationship to insured Secondary Insurance

Self

Spouse

Child

Other

PolicyHolder’s Name

MM/DD/YYYY Date of Birth

SSN

Address (if different from Above)

City

State

Zip

PolicyHolder’s Employer

Location

Phone

Patient’s relationship to insured

Self

Spouse

Child

Other

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

By my signature, I hereby authorize SoutTexas Eye Center to examine, treat, and perform diagnostic tests and office procedures that the physician deems necessary. I hereby allow South Texas Eye Center to furnish any information pertaining to my medical treatment to my insurance carrier, worker’s compensation representative, attorney, employer, or other providers of service. I agree that all payments made by my insurance will be to South Texas Eye Center. I understand I am ultimately responsible for any balance on my account.

Signed

Date

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