New Patient Form

New Patient Form

New Patient Form

New Patient Form

New Patient Form

New Patient Form

Patient Name

First Name*

Last Name*

Phone Number*

Home/Alternate Number*

Patient Birth Date

Date of Birth*

Home Address

Street Address*

City*

State*

Zip Code*

Email*

Emergency Contact Name

First Name*

Last Name*

Relationship to Patient*

Contact Phone Number*

Name of Primary Care Doctor*

Primary Care Doctor Phone Number*

Insurance Information

Primary Medical Insurance*

Name

ID

Secondary Medical Insurance*

Name

ID

Vision Insurance*

Name

ID

Primary Insured

First Name*

Last Name*

Date of Birth*

Street Address*

City*

State*

Zip Code*

Last 4 digit of the SS#*

Financial Acknowledgement

I hereby authorize any Visioncare Optometry, PC to furnish all facts concerning this claim. I authorize payment from my insurance(s) to go directly to Visioncare Optometry, PC. I agree that if my employer, insurance carrier, or plan sponsor denies payment to all or any portion of my claim, I will be financially responsible for all outstanding charges. Authorization obtained at the time of service does not guarantee payment.


​​​​​​​This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at the front desk. Please check if you would like a copy of our HIPAA policy emailed to you:

Signature
Date
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A30master none 10:00 AM - 4:00 PM 10:00 AM - 6:00 PM 10:00 AM - 6:00 PM 10:00 AM - 6:00 PM 10:00 AM - 5:00 PM 10:00 AM - 4:00 PM Closed optometrist https://www.google.com/search?q=perfect+eye+care+brooklyn+ny&ei=WB1nYf_oHOezqtsP1MalwAE&oq=perfect+eye+care+brooklyn+ny&gs_lcp=Cgdnd3Mtd2l6EAMYADIICAAQCBANEB4yCAgAEAgQDRAeMggIABAIEA0QHjoHCAAQRxCwAzoNCC4QxwEQrwEQDRCTAjoHCAAQyQMQDToKCC4QxwEQrwEQDToGCAAQDRAeSgQIQRgAUIIQWPcRYPMeaAFwAXgAgAGiAYgBsgKSAQMwLjKYAQCgAQHIAQjAAQE&sclient=gws-wiz#lrd=0x89c25cb48206d52d:0xc6097f2d1d33a9d3,1,,, https://www.facebook.com/brooklyneyedr/reviews/?ref=page_internal