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 ____________________________

Occupation _________________________________________________________________________

Primary Care Doctor ____________________________ Last Medical Exam _____________________

Medical Insurance and Policy Number ___________________________________________________

Vision Insurance: [ ] VSP [ ] Eyemed [ ] Other ____________________________________________

Electronic Communication:

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 _______________________________________________________________________