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Registration Form
NOTE: Any section with an asterisk MUST be completed. Otherwise any other sections should only be completed if necessary.
* Required
Patient Full Name:
*
Your answer
DOB:
*
MM
/
DD
/
YYYY
Preferred Contact Method:
*
Work
Email
Required
Phone:
*
Your answer
Home:
Your answer
Work:
Your answer
Address:
*
Your answer
Email:
*
Your answer
Gender:
*
Male
Female
Social Security Number (Last 4) :
*
Your answer
Race:
Your answer
Ethnicity:
Your answer
Marital Status:
*
Single
Married
Divorced
Separated
Other:
Employer:
*
Your answer
Status:
Full Time
Part Time
Clear selection
Student:
Yes
No
Clear selection
School Name:
Your answer
Insurance Information
VISION / MEDICAL PLAN:
*
CIGNA - (HMO, PPO)
ENVOLVE VISION - (Ambetter, Ascension Complete Medicare, CMS, Sunshine Health, Wellcare for Sunshine Health)
EYEMED - (Aetna, Anthem Blue View Vision, Humana, Unicare)
PREMIER - (Humana, Molina, WellCare Medicaid, WellCare Medicare)
MEDICAID
MEDICARE
iCARE (Simply Healthcare, 20/20 Eyecare)
SPECTERA - (United Health Care - Vision)
SUPERIOR VISION
TRICARE - (Humana Military, Tricare Prime)
VSP - (Metlife, Cigna Vision, Anthem Blue Cross, Spectera)
NONE
Other:
Required
Insurance Company Phone Number:
Your answer
Identification Number:
*
Your answer
Group Number:
Your answer
Address:
Your answer
Patient
*
Your answer
Relationship to patient
*
Your answer
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