New Patient Registration


Last Name*

First Name*

Middle Initial (optional)

Preferred Name*


Home No.

Cell No.*

Work No.


Best Way to Contact:

Emergency Contact/relationship (Optional)



Patient Ssn (Optional):

Date of Birth


(if a Minor) Parent's Name

Spouse's Name

Are You: (Optional)

Who May We Thank for Referring You to Our Office? (Optional)

Vision Plan Information

Vision Plan

Subscriber Ssn/id#*

Subscriber Name*:

Subscriber Birth Date:*

Relationship to Patient:

Medical Insurance Information

Primary Medical Insurance

Subscriber Ssn/id#*

Subscriber Name*:

Subscriber Birth Date:*

Secondary Medical Insurance?

Secondary Medical Insurance?

Subscriber Ssn/id#*

Subscriber Name:

Subscriber Birth Date:*

Who May We Thank for Referring You to Our Office? (Optional)

Lifestyle Questions (Check All That Apply)

Contact Lens Info:

Do you wear contact lenses?


Financial Information

In order to control the cost of billing, we ask that the patient’s portion is paid at the time services are rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge of $25 on all returned checks. Payment from my vision plan/medical insurance is to be paid directly to Clearfinity Eyecare Optometrist and I understand that (name of vision plan or medical insurance) will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made once the claim is processed. All eyewear purchases are final sale and only a store credit can be issued that can be used for any future eyewear purchases.

Privacy Practices

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree you are bound to abide by such restrictions.


Patient Name:*

Patient Medical History

Family Physician:


Last Physical Check-up:

Current Medications (Prescription or Over-the-counter)

Allergies to Medicines?

Patient Eye History

Date of Last Eye Exam:

By Whom?

Have you had any eye-related surgeries of any kind?

What Are the Main Reason (S) for Your Visit? (check all that apply)

Check Eye Conditions That You Have Been Diagnosed:

Family History: Relationship (Mother/father/sister/brother/grandparent)

About Your Vision Plan/medical Insurance

There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts one or both:

  • Vision Care Plans (such as VSP, Davis, Eyemed etc..)

  • Medical Insurance (such as Blue Cross/Blue Shield and United Health Care etc..)

  • Vision care plans ONLY cover ROUTINE vision exams along with eyeglasses and contact lenses. Vision plans only cover a basic screening for eye disease. They DO NOT cover diagnosis, management, or treatment of eye diseases, dry eye, itchy eyes, cataracts etc...

  • Medical insurance MUST be used if you have any eye health problem or systemic health problem that has ocular complications. (e.g. dry eye, red eye, eye pain, itchy eyes, discharge from eyes etc..) Your doctor will determine if these conditions apply to you, but some are determined by your case history or reason for your visit.

  • If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your out-of-pocket expense.

  • We will bill your insurance plan for services if you we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pays or non-covered services as allowed by the insurance contract.

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Today's Date: