Patient Registration information

First Name
Last Name
Middle Initial
Date of Birth
Social Security#
Age
Gender MaleFemale
Marital Status SingleMarriedDivorcedSeparatedWidowed

Address
City
State
Zip Code
Home Phone
Cell Phone
Email
Spouse/Guardian's Name (if applicable)
Ethnicity Hispanic or LatinoUnknownNot Hispanic or LatinoDecline to Provide

Race American Indian or Alaskan nativeAsianBlackWhiteUnknownHawaiian Native or Pacific IslanderDecline to Provide

Primary Care Physician
Pharmacy Name/Phone
Primary Language
Referred by
Patient's Employer
Business Address/Phone
In case of emergency, who should we contact?
Phone
Is this a Workman's Compensation Case? YesNo

Complete if Patient is Under 18 years/Student
Other Parent/Guardian
Home Phone
Address (if different from patient's)
Work Phone
City
State
Zip Code

I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled including Medicare, private insurance and any other health plans to Brown Eye Care Associates. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all services rendered that are considered out of network or any balance that is not covered by my insurance carrier. I authorize the use of this signature on all insurance submissions. I authorize Brown Eye Care Associates to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.

Capture a picture of your insurance front and back

Today's Date:
Signature of Responsible Party

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