New Patient Registration Form

NEW PATIENT REGISTRATION

In order to provide you the best possible care, please complete this form
and bring it to your first appointment. All information is strictly CONFIDENTIAL.

Contact Information

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Guardian Information (if patient is under 18 years of age)

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Patient Information

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Primary Insurance Information

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Secondary Insurance Information

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Additional Insurance Information

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Financial Assignment Information

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Acknowledgment of Notice of Privacy Practices (NPP)

PATIENT HISTORY

Vision Correction History (please check any that apply

Glasses History (check all that apply)

What glasses do you own?
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Check any that apply

Contact Lens History (check all that apply)

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Check any that apply
Family History (check all that apply)
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General Medical History (please answer appropriately)

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Do you have any of the following?
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Referral Information

Why did you visit us?

Keep in touch

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Questions and notes

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Please do not submit any Protected Health Information (PHI).

Hours of Operation

Monday  

10:00 am - 6:00 pm

Tuesday  

10:00 am - 6:00 pm

Wednesday  

Closed

Thursday  

9:00 am - 5:00 pm

Friday  

9:00 am - 5:00 pm

Saturday  

9:00 am - 3:00 pm

Sunday  

Closed

Contact Us

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Please do not submit any Protected Health Information (PHI).

655 Sunland Park Dr Suite E-1B El Paso, TX 79912