Webb & Associates Family Eyecare

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
First Name
Last Name
Daytime Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Email
example@example.com
Street Address
Suite/Apt
City
State
Zip Code
Guardian Information (if patient is under 18 years of age)
First Name
Last Name
Daytime Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Email
example@example.com
Street Address
Suite/Apt
City
State
Zip Code
Patient Information
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security No.
Primary Insurance Information
Provider Name
Provider Phone
Format: (000) 000-0000.
Policy/I.D. No.
Group No.
Secondary Insurance Information
Provider Name
Provider Phone
Format: (000) 000-0000.
Policy/I.D. No.
Group No.
Additional Insurance Information
Provider Name
Provider Phone
Format: (000) 000-0000.
Policy/I.D. No.
Group No.
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)
Signature agreeing to all above terms
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

NEW PATIENT REGISTRATION