NEW PATIENT INFORMATION Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastNicknameDate of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeSS#AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneWork PhoneEmail Address *Civil StatusSingleMarriedWidowedDivorcedEmergency Contact Person Emergency Contact Person NumberPerson(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?YesNoEmployer: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 InsuranceID#NAME:Date of BirthLast 4 of SS#Relationship to Patient:Phone NumberName of Insurance ID#NAME: Date of BirthLast 4 of SS#Relationshop to Patient:Phone NumberMedical 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 NameDateEmailSubmit