Patient Welcome Form

Monday: 10:00 AM - 5:00 PM
Tuesday: 10:00 AM - 7:00 PM
Wednesday: 10:00 AM - 7:00 PM
Thursday: 10:00 AM - 5:00 PM
Friday: 10:00 AM - 3:00 PM
Saturday: 10:00 AM - 2:00 PM
Sunday: Closed

For faster service, please complete the following form prior to arriving at our office.

Appointment Date
Patient’s Name
First Last
If a Child, Parent’s Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Home Phone
Work Phone
E-mail Address
Gender
- Male
- Female
Birth Date
Employer
Occupation
Spouse’s Employer
Work Phone
Health 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.
Signature
Date

Mt. Airy Medical Eye Center