Registration Form Name*(adults only, please specify title) Mr.Ms.MissDr. Title First Middle Last Preferred Name Date of Birth* MM slash DD slash YYYY Social Security Number*(last 4 digits only) Primary Phone*Secondary PhoneAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name* Emergency Contact Phone*Children in FamilyNameAge Referred By Family Member Online Insurance Provider List Other If family member, please specify: If online, please specify: If insurance provider list, please specify: If other, please specify: Complete this section if patient is under 18 years of ageParent/Legal Guardian Name First Last Parent/Legal Guardian Social Security Number If student, grade 1-6, write school, grade and teacher's name.School Grade Teacher's name Occupation Employer Email* Primary Care Physician* Last Exam Date* MM slash DD slash YYYY City* State*--Please Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPlease list any additional persons you authorize to access your personal health information (PHI), including billing and medical records information:Full NameRelationship Insurance InformationPrimary Insurance Plan:Name of Insurance Insured Patient's Name Insured Patient's ID Number Group Plan Name/Number Relationship to Policyholder Self Spouse Child Other Secondary Insurance Plan:Name of Insurance Insured Patient's Name Insured Patient's ID Number Group Plan Name/Number Relationship to Policyholder Self Spouse Child Other Race* American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian White Declined to Specify Other Race Ethnicity* Hispanic or Latino Not Hispanic or Latino Declined to Specify Language* English Spanish French Arabic Height*ft/in Weight*lbs PAYMENT IS DUE AT THE TIME SERVICES ARE RENDEREDIf you have insurance coverage for these services or materials and we are current providers, we will submit claims for you. However, we are not liable for collecting your claim. After 30 days, we will expect payment in full from you if your insurance company has not paid. I hereby authorize my insurance carrier to make payment directly to Five Points Eye Care Center. I understand that I am financially responsible for all charges whether ot not they are covered by insurance or other entities. I also authorize release of any information regarding my treatment or condition in order to obtain payment for services. I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any services rendered. I have read all the information on this sheet and have completed the above questionnaire. I certify that this information is true and correct to the best of my knowledge. I agree to notify this office of any changes in my insurance status ot the above information.Signature*Date* MM slash DD slash YYYY Parent/Guardian Signature (if minor)Date MM slash DD slash YYYY