Welcome to Our Office For faster service, please complete the following form prior to arriving at our office. Appointment Date MM slash DD slash YYYY Patient’s Name First Last If a Child, Parent’s Name First Last Address 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 Home PhoneWork PhoneE-mail Address Gender Male Female Birth Date MM slash DD slash YYYY Employer Occupation Spouse’s Employer Work PhoneHealth Insurance Carrier Policy # Medicare/Medicaid Policy # How did you find out about our office? I authorize the release of any medical information necessary to provide the most beneficial and complete visual examination. I understand that I am financially responsible for all charges whether or not paid by insurance. Payment is due at the time services are rendered.SignatureDate MM slash DD slash YYYY