NEW PATIENT INFORMATION - Eye Doctor in Mobile Alabama

Name *

First

Middle

Last

Nickname

Date of Birth

Age

SS#

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address *

Civil Status

Emergency Contact Person

Emergency Contact Person Number

Person(s) We Can Discuss and/or Release your health information to:

Add names or self only.

May we email/text about appointments or other health information?

Employer:

Occupation

In most cases contact lenses are not considered **medically necessary ** by insurance companies. Any test performed to determine or update a contact lens prescriptions may not be covered by insurance companies and will be the responsibility of the patient.

Name of Insurance

ID#

NAME:

Date of Birth

Last 4 of SS#

Relationship to Patient:

Phone Number

Name of Insurance

ID#

NAME:

Date of Birth

Last 4 of SS#

Relationshop to Patient:

Phone Number

Medical Release Authorization and Insurance Assignment: *

I, the undersigned authorize payment from my insurance company to be made to BarKing Optical, Inc. for covered services. I understand that I am responsible for obtaining any referrals needed before my appointment or I must pay for that visit. Regardless of my insurance status, I am ultimately responsible for the balances of my account. Should timely payments of this account not be made, I authorize BarKing, Inc. to retain the services of an attorney and/or collection agency to assist with the collection of any outstanding balance. Any expenses incurred by such action shall become an additional liability for which I am responsible. I certify that the information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled, this authorization may be revoked by myself at any time in writing. I have reviewed a copy of the Privacy Practice Notice (located on the wall) at BarKing Optical, Inc.

Print Name

Date