Home » Hours & Locations » Contact Us » Online Patient Registration Form

Online Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

  • (optional)
  • Primary Insurance

  • Eye Signs and Symptoms

  • Glasses/Contact History

  • Eye History

  • Please check any that apply.
  • Please check any that apply.
  • Medical History

  • Add a new row
  • Add a new row
  • Add a new row
  • Add a new row
  • For example: Diabetes, Hypertension, Cancer, Glaucoma, Macular Degeneration, etc..
    Add a new row
  • INSURANCE AUTHORIZATION

    I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS OR OTHER INSURANCE BE MADE EITHER TO ME OR ON MY BEHALF TO REGIONAL EYE CENTER FOR ANY SERVICES FURNISHED ME. I AUTHORIZE HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.

  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform Regional Eye Center of any changes in medical status. I also understand that I am responsible for all charges incurred.