lock icon Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office. This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Most medical health insurance plans do not cover Routine Vision and or dental plans. Vision Plans are typically considered supplemental coverage and typically have a specific ID# or use your SSN. It is the member's responsibility to know their insurance coverage and to provide information at the time of appointment.

Appointment cancellations need to be made 24 hrs in advance to your scheduled visit to avoid cancellation fees.

Step 1 of 9

Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*

Please provide a telephone number, with area code, so we can contact you.
Daytime Phone
Cell Phone
Email Address*

Please provide us your email address.

Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)*
Please enter a number from 0000 to 9999.
Preferred Language*
Marital Status
Marital Status - Other

Please provide your marital status.
Employment Status
Employment Status - Other

Please provide your employment status.
Employer
Occupation
How were you referred to our office?*
Referral Status - Other

Please let us know how you were referred to our office.
Communication Preference*
New or Returning Patient*
- New
- Returning
Reason For Visit*

Contact Lens History
Do you wear contact lenses?*
- Yes
- No
What brand of contact lenses do you wear?
How old are your current lenses?
How often do you replace or dispose your contact lenses?
What brand of solution do you soak your lenses in?
What is your typical wearing schedule? In hours per day:
Please enter a number from 0 to 24.
What is your typical wearing schedule? In days per week:
Please enter a number from 0 to 7.
Please check off all that apply to you
- I am having problems with my current contact lenses
- There are times when I would rather not be wearing contact lenses
- I am interested in changing or enhancing my eye color
- I am interested in a non-surgical method of vision correction
- I am interested in refractive laser surgery
- I don't have a spare set of contact lenses
- My spare contact lenses have an incorrect prescription

Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured

Comments
If you have any comments you would like to add, please enter them here.

Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Comments
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Eye Emergency

Online Patient Registration Form

Step 1 of 9

Patient Information

Personal Information

Eye History

Glasses History

Contact Lens History

Medical History

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Ridgeview Optometry