New Patient Form
Thank you for choosing Clarity Eye Care, PLC for your eye care needs. We are committed to providing you with the highest quality vision care in a timely and cost effective manner. Please take a moment to answer the questions below.
Full Name: _____________________________________________ Birth date: _________________________
When was your last eye exam? ___________Where was your last eye exam ? ___________________________
How did you hear about us? [ ] Newspaper [ ] Internet/Web Page [ ] Facebook [ ] Family/Friend
[ ] Other___________________________________________________________
We like to thank those who have referred you to our office. Please list the name of that person below:
Name of referrer : __________________________________________________________________________
IF YOU HAVE COMPLETED YOUR REGISTRATION THROUGH OUR PATIENT REGISTRATION PORTAL YOU MAY STOP HERE. OUR PORTAL CAN BE FOUND AT https://compulinkadvantageweb.com/register/accountappts/index/7024
Full Legal Name : _____________________________________ Preferred Name: _______________
Date of Birth: ______________________________ last 4 digits of social security # ______________
Address: ___________________________________ Home Phone _____________________________
___________________________________________ Cell Phone ______________________________
Employer: ___________________________________ Work Phone ____________________________
Primary Care Doctor ____________________________ Last Medical Exam _____________________
Medical Insurance and Policy Number ___________________________________________________
Vision Insurance: [ ] VSP [ ] Eyemed [ ] Other ____________________________________________
In an effort to be in compliance with recent government regulations, we are asking that you share your email address with us. We will be using this address to give you electronic access to information related to your exam including the ability to view diagnosis and plan information obtained during your examination.
There may also be a limited number of emails regarding appointments, recalls, or other incidental information. If you would prefer to not receive those additional emails and only receive a link for medical chart access please check and initial here [ ] ________.
Email address _______________________________________________________________________