Forms - White Eye

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Date*
MM slash DD slash YYYY
Patient's Last Name*
Patient's First Name*
Patient's Middle Name
Social Security #*
Date of Birth*
Sex*
- Male
- Female
Address*
City*
State*
ZIP*
Race
Language
Home Phone
Day/Cell Phone*
Email*
Emergency Contact Name
Relationship to Patient
Contact/Alternate Phone
Patient's Employer
Work Phone
Person Responsible for Paymemt
Relationship
Primary Insurance Company*
Policyholder Name*
Policyholder Date of Birth*
ID #*
Group #*
Relationship to Policy Holder*
Secondary Insurance Company
Policyholder Name
Policyholder Date of Birth
ID #
Group #
Relationship to Policy Holder
Patient Portal: I would like access to White Eye Associates' secure patient portal where I can:*
- Review and verify my contact information
- Input medical history / medications / pharmacy information
- View handouts
- Communicate with staff
Name of Pharmacy
Pharmacy Phone / Location
Name of Primary Care Doctor
Phone
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Comments
This field is for validation purposes and should be left unchanged.

Insurance Cards(s)

Photo I.D.

Co-Payment (cash, check, credit card)

Your prescription eyeglasses and/or contact lenses

List of medications/eye drops