Registration
PATIENT INFORMATION	Name: Date of Birth: Ex. 03/29/1976 Sex: Male Female SSN: Ex. 555-55-5555 Parent/Guardian Name: Address: City: State: Zip: Home Phone: Alternate Phone: Email: In Case of Emergency Contact: Name: Relationship: Phone:
INSURED INFORMATION	Employer of Ins'd: Name of Ins. Holder Ins. Holder Date of Birth Ins. Holder SSN #
PERMISSION TO TREAT	I give Clarksville Eye Clinic and its optometrists permission to examine, diagnose, and treat as necessary myself or the minor on this sheet. Initial:     Date:
SIGNATURE ON FILE AUTHORIZATION	I request and authorize that payments made by Medicare or other insurance companies be made to Clarksville Eye Clinic on my behalf for any services provided to me by Clarksville Eye Clinic or its optometrists. Initial:     Date:
RESPONSIBILITY STATEMENT	I further understand that I am responsible for the entire bill for services provided even though insurance has been filed on my behalf. Insurance is filed as a courtesy to our patients and every effort will be made to verify benefits prior to being seen. Insurance co-payments and/or deductible are due at time of service. I assume responsibility for all fees that are incurred if my account requires collection or an attorney. Initial:     Date:
RELEASE OF INFORMATION	I give permission to Clarksville Eye Clinic to release all medical and financial information related to the above individual to the following people: 1: 2: 3: 4: or None Initial: Date: Signature: Date:
SUBMIT TO CLARKSVILLE EYE CLINIC