Online Patient Registration

Please fill out the form below and click the Submit button at the bottom of the page upon completion.

 

Patient Information

First Name:		Last Name:		MI:		Nickname:
Birthday:		Gender:	Male Female			Marital Status:	Single Married

Street Address:		City:	State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY	ZipCode:
Home Phone:		Work Phone:
Cell Phone:		Other Phone:
Occupation:
Employer:

 

Vision Insurance Information

Insurance Name:	None Aetna Amerihealth Anthem Bluecross Asuris Carpenters Trust Cigna Davis Vision EBMS First Choice First Choice- Swedish Hospital First Health Great West Health Comp Healthcare Management Administrators HUMANA KPS Health Plans Lifewise MEDICARE METLIFE Mutual of Omaha New Insurance Northwest laborers Operating Engineers Health Optum Health Pacificare Premera Bluecross Principal PRIVATE puget sound electrical workers Regence BlueShield FEP Regence Boeing Regence Group Administrators Regence Med Advantage Regence PPO Seattle Plumbing and Pipefitters Secure Horizons Sound Health and Wellness Sterling TRUSTEED Trusteed Plans Trusteed Plans Service Corp Uniform Medical Plan Unions & Foods employers benefit plan UNITED VSP WABAKERS WPAS Zenith Administrators
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
Employer/School:

 

Medical Insurance Information

Insurance Name:	None Aetna Amerihealth Anthem Bluecross Asuris Carpenters Trust Cigna Davis Vision EBMS First Choice First Choice- Swedish Hospital First Health Great West Health Comp Healthcare Management Administrators HUMANA KPS Health Plans Lifewise MEDICARE METLIFE Mutual of Omaha New Insurance Northwest laborers Operating Engineers Health Optum Health Pacificare Premera Bluecross Principal PRIVATE puget sound electrical workers Regence BlueShield FEP Regence Boeing Regence Group Administrators Regence Med Advantage Regence PPO Seattle Plumbing and Pipefitters Secure Horizons Sound Health and Wellness Sterling TRUSTEED Trusteed Plans Trusteed Plans Service Corp Uniform Medical Plan Unions & Foods employers benefit plan UNITED VSP WABAKERS WPAS Zenith Administrators
Insurance ID:
Insurance Policy Group:

Not Primary on Account: Not Primary

Primary on Account

Name:	Last, First MI
Relationship to Insured:	Spouse Child Other
Sex:	Male Female
Address:
City:	State: Zip:
Phone Number:
Birthday:
Employer/School:

 

Patient Health History

Please list any medications that you are allergic to.
Medication allergies:
Please list any other allergies you have.
Other allergies:

Do you or your family blood line relatives have any of the following medical conditions? (list all that apply in the corresponding text areas)
Allergies		Depression		Kidney Disease		Stroke
AIDS/HIV		Asthma		Hepatitis		Lupus
Migraines		Thyroid		Diabetes		Heart Condition(s)
Hypertension		Cancer		Arthritis
You:			Family:
Have you or your family blood line relatives had any of the following eye conditions? (list all that apply in the corresponding text areas)
		Glaucoma		Macular Degeneration
		Loss of Sight		Detached Retina
		Cataract(s)
You:			Family:

Please list any medications you are currently taking.
Medications: