Wufoo

Patient Registration - Shepherd Hills Eye Care

Thank you for taking the time to complete your registration forms in advance. Doing so allows us to prepare for your visit in advance and will save you time at your appointment. Your answers will then be transferred directly to our office by secure email.

Patient Information

Please answer the following questions as completely as possible.
Patient Name * Title First Last Suffix
Include middle name or middle initial with First name.
Nickname

By what name would you like us to refer to you?
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth * MM / DD / YYYY
Gender *
Male Female
If patient is a dependent, name of parent or guardian Title First Last Suffix
Relationship to patient
Address of parent or guardian, if different from patient
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Number * ### - ### - ####
Cell Phone Number ### - ### - ####
Work Phone Number ### - ### - ####
Work Phone extension (if any)
Maximum Allowed: 6 digits. Currently Used: 0 digits.
Email Address
What is your preferred way to be contacted?
Occupation

If patient is a student, please enter "student".
Employer

If patient is a student, please note school attending.
If patient is a student, what grade?
Marital Status
Name of Spouse First Last
Who is your primary care physician? First Last
What is the name of your physician's practice?
If known, what is your physician's address?
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
How did you hear about our office? (Check all that apply)
Insurance listing Internet search Yellow Page ad Received mailing Saw sign driving by Referred by relative Referred by friend Referred by co-worker Other family members are patients here Other, not listed here
Is there someone we can thank for referring you to us?
VISION BENEFITS INFORMATION

Please enter your Vision Benefit information below. Please note: Our office will use this
information to obtain your insurance eligibility and coverage amounts in advance of your visit.
What is your primary VISION insurance benefit plan (if any)? *

Note: If your insurance company is not listed here, we may not be a provider for your plan. Please contact the office to inquire.
Who is the subscriber?
What is the ID number of the vision insurance?
If patient is not the subscriber, what is the subscriber's date of birth MM / DD / YYYY
MEDICAL INSURANCE INFORMATION

Please enter your MEDICAL INSURANCE information below.

Q: Why do we ask for your medical information?

A: At times patients are determined to have medical eye conditions that require medical treatment or ongoing observation. Vision insurance benefit plans cover only routine vision care and not medical eye care. However, medical insurance plans most often will cover medically-related eye care.
What is your primary MEDICAL INSURANCE plan (if any)? *

Note: If your insurance company is not listed here, we may not be a provider for your plan. Please contact the office to inquire.
Who is the subscriber?
If patient is not the subscriber, what is the subscriber's date of birth? MM / DD / YYYY
If "Other", what insurance is it?
Insurance Authorization and Financial Agreement

"I authorize Shepherd Hills Eye Care Center to release to my insurance company any information needed to determine the benefits for services rendered to me. I further authorize that payments of benefits, including Medicare, private insurances and any other health care plans, be made directly to Shepherd Hills Eye Care Center."

"I understand that I am responsible for all charges for services and materials provided to me, less any amounts received from insurance or third party payers and guarrantee payment of this account."

Please note: Payment is expected when services are rendered. If insurance applies, all applicable co-payments and deductables are due at time of visit. Our office does not bill for professional services or laboratory materials. For your convenience, our office accepts cash, personal checks, Visa, Mastercard and Discover.
I accept
Name of person filling out this form
Date MM / DD / YYYY
What is your relationship to the patient?
Do Not Fill This Out

Wufoo

Patient Registration - Shepherd Hills Eye Care

Patient Information

VISION BENEFITS INFORMATION

MEDICAL INSURANCE INFORMATION

Insurance Authorization and Financial Agreement