Online Registration Form

At Innovative Eyecare, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

​​​​​​​Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

PATIENT INFORMATION
Last Name:
First Name:
Middle Initial:
Street / City
State / Zip
Telephone
Date of Birth:
RESPONSIBLE PARTY (If different from above)
Last Name:
First Name:
Middle Initial:
Street / City
State / Zip
Telephone
Date of Birth:
Relationship to Insured
MEDICAL HISTORY
Do you currently wear corrective eyewear?
If Yes, please check all that apply:
Approximately when was your last eye exam?
Doctors Name:
City, State, Phone:
INSURANCE / VISION CARE COVERAGE
Name of Insurance:
ID No.:
Subscriber Name:
Relationship:
Secondary Insurer (if any)
ID No.:
WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE
Name:
Name:
Name:
May we contact you by e-mail? note: information will not be shared with any outside parties
AUTHORIZATION
PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE:

I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of benefits either to myself or to the party who accepts assignment. I understand that I am responsible for any balance due for services and/or products that are deemed "not covered" or denied or delayed (over 60 days) by my benefit plan.

RELATIONSHIP TO PATIENT IF OTHER THAN SELF:
4055092288