Welcome To Our Office Form - West Linn Vision Center
ADVERTISEMENT
1West Linn Vision Center
WELCOME TO OUR OFFICE
Patient Information
Last:_______________ _
____ First:_____
__
__ __
__ _____ MI___
___
Preferred Name:__________ ________Date of Birth: _______
_Sex:
M
F_
SSN:__
__
Address: ______
__________________
City: _____________
____
___ State: _
__
_ ___ Zip: __
___
Email: ___________
_________________
Phone: (h) ____ ______
_______
_ ____ (w) _________
___ ________ (c) _______
___________
Emergency Contact:_________________
_____Phone:______________________________________
Person Responsible for Account: ___________
____
_____
Insurance Information
Primary Vision:______________________ ____ _ _ Primary Medical:_________ ___ ____ ______
______
ID #________________________________
_
ID #_____________
_______
_________
____
Guarantor Name__________________________
_ Guarantor Name:_________________
____
______
D.O.B.__________________________________
__D.O.B._____________________________
______
Employer:___
_ Employer:_
__
Signature:
___ ________ _______ ______________ ___ ____Date: _______________
New Patients Only:
Who may we thank for referring you to our office?
Name of friend, relative, or another Doctor? ________________________________________________________
If not referred, how did you choose our office?
□ Insurance List ________________________________
□ Saw Sign / Building
□ Newspaper / Radio / TV ________________________
□ Yellow Pages: Which directory? __________________
□ Web Page: Which Website? _____________________
□ Other: ______________________________________
Tigard, Murray Scholls, and West Linn Vision Centers are family owned and operated,
offering over 50 years of vision care expertise.
•
We believe in building a personal relationship with each patient, providing the best possible experience from check-in to check-out.
•
We strive to educate every patient about their eyes, arming them with the knowledge to maintain good eye health and optimum vision.
•
Our doctors utilize state-of-the-art instrumentation to prevent, detect and monitor a variety of ocular diseases, ensuring the best
quality eye care for all patients.
•
Our commitment is to provide a lifetime of expert eye care to each and every patient.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical