Legacy Eye Care
Modernized Optometry, Affordable Quality Care

Patient Registration

Legacy Eye Care Registration Form

Click Edit Form to add form elements. You can enter a form description and instructions here.

 Patient Name:  
Address: 

Phone Number:
Date of Birth:
  Male
  Female
Social Security #:

Spouse or Parent’s Name: ___________________________________________________

Whom may we thank for referring you? ____________________________________________________________

Emergency Contact Person: ____________________________________ Phone (_______)_____________________

Email Address: _____________________________________________________

Person Responsible for Bill (If different from patient)

Name: __________________________________________ Relationship to Patient: _________________________

Address: ______________________________________ City _________________ State __________Zip__________

Phone: (________)________________________Work Phone: (________)____________________________

Insurance Information

Primary Medical Insurance Co: ________________________________Relationship to Pt. ______________________

Name of Insured: __________________________________________________Date of Birth: __________________

Name of Employer: _________________________________________ Work Phone(_______)___________________

ID#_______________________________________Group#____________________

Secondary Medical Insurance Co: _________________________________________________________________

Name of Insured: ________________________________________________Date of Birth: ___________________

Name of Employer: _______________________________________ Work Phone(_______)___________________

ID#_______________________________________Group#____________________

Vision Insurance: Advantica, Superior Vision, Davis Vision, Eye Med,Anthem, Medicaid, Medicare, Tricare, Optima, United Health Care

Name of Insured: ________________________________________________Date of Birth: ___________________

Name of Employer: ____________________________________ Work Phone(_______)_________________