Patient Pre-Registration Form

PATIENT INFORMATION

Date*

Please Pick One:*

Mr.
Miss
Mrs.
Ms.

Name*

First Last

Date of Birth*

Sex*

Male
Female

Marital Status*

Single
Married
Divorced

Race*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone

Employer*

Work Phone

Email Address*

Emergency Contact Name*

Emergency Contact Phone Number*

Referring Doctor

Referring Doctor Phone Number

Referring Doctor Address

Street Address Address Line 2 City State ZIP Code

PARENT/GUARDIAN/POWER OF ATTORNEY INFORMATION

Name

First Last

Social Security Number

Race

Date of Birth

Sex

Male
Female

Marital Status

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email

Relationship to Patient

Please Pick One:

Parent
Gaurdian
Power of Attorney

INSURANCE INFORMATION

Primary Insurance*

Name of Policy Holder*

Policy Holder's Date of Birth*

Policy Holder's Social Security Number*

Relationship to Patient*

Secondary Insurance

Name of Policy Holder

Policy Holder's Date of Birth

Policy Holder's Social Security Number

Relationship to Patient

Tertiary Insurance

Name of Policy Holder

Policy Holder's Date of Birth

Policy Holder's Social Security Number

Relationship to Patient

PLEASE ANSWER THE FOLLOWING QUESTIONS:

I may be contacted by the office at (check all that apply)*

Home
Work
Cell
Email

How did you hear about us?*

Who, other than the noted emergency contact above, should be listed as an authorized individual we can release any medical information to if need be?

First Last

Phone

Relationship

PRIVACY NOTIFICATION:*

I have received a copy of the Notice of Privacy Practice for Cornea Consultants of Nashville. Cornea Consultants of Nashville reserves the right to modify the privacy practices outlined in the notice.

By checking the box below, I acknowledge that I have completed the information to the best of my knowledge and I have read and understand and voluntarily consent to its contents.
https://www.corneaconsultants.com/privacy-policy/

I agree. (This Box is Required to be Checked Prior to Submission)

Date*