Welcome to Golden Eye Optometry, Inc. EyeCare Registration Patient Information

Date:________________________ Last Name:__________________________________ First Name:___________________Initial:__________ Title: Mr. Ms. Miss Mrs. Dr. Address:____________________________________ City:________________________________________ State:_______________________Zip:____________ Home Phone:________________________ Cell Phone:______________________ Email Address: _______________________________

Emergency Contact Information: Name:_____________________________________ Telephon Number:__________________________ Relation:___________________________________

SS# ___________________ DOB________________

Sex: Male Female

Single Married Separated Divorced Widowed Employer: _____________________________ Occupation: ___________________________ If Student Check Here: Preferred Name: _______________________ How did you select our office? Referred by: __________________________

Family has been in Insurance Co. Flyers/Coupon Health Professional Other _________________________________

Are you interested in Lasik? Yes No

If the patient is a child: Parent's Name & Address & Phone (if different)

_____________________________________________________

_____________________________________________________

Vision Insurance Information Primary Insurance Co. _____________________________ Insurance ID# ____________________________________ Patient Relationship to Insured: Self Spouse Child Other______________Insured Name: Same as Patient (Last, First, MI)___________________________________ Date of Birth______________________________________ MEDICAL Insurance Co. ____________________________ Insurance ID# _____________________________________ PPO_______________ OR HMO_____________________ Patient Relationship to Insured:_______________________ Self Spouse Child Other ________________ Insured Name: Same as Patient(Last, First, MI)_____________________________________Date of Birth____________________________

Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice in person or by calling our office at (760) 948-3345.If you have any questions about our Notice of Privacy Practices, please ask one of our staff members.

I hereby acknowledge that I received a copy of the Notice of Privacy Practices of Golden Eye Optometry, Inc.

Signature of Patient or Representative:

If Representative, give relationship:

Date:

Note: Most insurance policies pay only a portion of your total charges. If you have any questions about your coverage, please contact your representative. Please understand that financial responsibility of your account is yours, not your insurance company’s. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.

_________________ __________ Signature of Patient/ Guardian Date

Preferred Language: ________________________ Race: Asian African American

Hispanic Nat IndianEthnicity : Hispanic Contact: Postal

Not Hispanic Email

White

Acknowledgement of Receipt of Notice of Privacy Practices

Native HawaiianPhone