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Located 1 block east from the corner of Dysart and McDowell
Right after Fry’s Market in Avondale, AZ

Call 623-232-0623

Request an Appointment Online

Hours & Location
Our Eye Doctors Near You in Avondale
Eye Care Services
- Your Eye Health
Eyeglasses
Contact Lenses
“Hard-to-Fit” Contacts
Insurance

Hours & Location
Our Eye Doctors Near You in Avondale
Eye Care Services
- Your Eye Health
Eyeglasses
Contact Lenses
“Hard-to-Fit” Contacts
Insurance

Home » New Patient Welcome Form

New Patient Welcome Form

Please note: This form must be completed in full before you can submit it.
If there is nothing to list, write “N/A” (not applicable).
PAYMENT IS REQUIRED AT THE TIME OF SERVICE.

Legal Name*
Prefix First M.I. Last
Today's Date*
Gender
- Male
- Female
Birthdate*
MM
DD
YYYY
Social Security Number
Nickname
Marital Status
- Single
- Married
- Widowed
- Divorced
Employment Status
- Student
- Retired
- Self-Employed
- Full-Time
- Part-Time
Employer
Occupation
Home Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone*
Email Address
OK to text?*
- Yes
- No
Emails and Texts are used to communicate with you for appointment confirmations, updates, etc.
Is patient a minor?*
- Yes
- No
Parent Legal Name*
First Last
Date of Birth*
MM
DD
YYYY
Parent Legal Name*
First Last
Date of Birth*
MM
DD
YYYY
Do you participate in or have an FSA or HSA?*
- Yes
- No
Referred by
Patient Professional
PLEASE CHECK OFF ONLY ONE IN EACH OF THE FOUR CATEGORIES BELOW:
Language
- English
- Spanish
Race
- American Indian or Alaskan Native
- Asian
- Hispanic
- White
- Black or African American
- European
- Native Hawaiian or Other
Ethnicity
- Not Hispanic or Latino
- Hispanic or Latino
- Native Hawaiian or Other Pacific Islander
Communication Preference
- Telephone
- Email
- Postal
- Text
NOTE: All Patient information is kept strictly confidential. Your information is NEVER shared.
INSURANCE INFORMATION
MEDICAL AND VISION

Please fill out completely.
If there is nothing to list, write “N/A” (not applicable).
VISION INSURANCE*
- VSP
- VCP
- VCD
- EYEMED
- MERITAIN
- Self Pay
Primary Member*
Name MEMBER ID
Patient's Relationship to Primary Member*
- Self
- Spouse
- Child
Date of birth*
MM
DD
YYYY
We require a copy of your vision insurance card to copy for the records, if applicable.
Do you have medical insurance?*
- Yes
- No
Name of Primary Medical Insurance*
Primary Member*
Name Member ID Member SSN
Patient's Relationship to Primary Member*
- Self
- Spouse
- Child
Date of birth*
MM
DD
YYYY
Employer
Group #
Do you have secondary insurance?*
- Yes
- No
Name of Secondary Medical Insurance*
Primary Member*
Name Member ID Member SSN
Patient's Relationship to Primary Member*
- Self
- Spouse
- Child
Date of birth*
MM
DD
YYYY
Employer
Group #
We require a copy of your Medical Insurance card to copy for the records, if applicable.
Patient Consent: The above questions were answered to the best of my knowledge. I authorize the release of information pertaining to this vision or medical examination to my insurance carrier(s), my physician(s), concerned eye care professionals, or in the case of a child, educational specialists (teachers, school nurse, etc.) under the following conditions: 1) detailed description of the information being released; 2) to whom may the information be released; 3) the purpose for the release; 4) expiration date or event. In the case of a minor, I (the parent/legal guardian authorize Estrella Mountain EyeCare PLLC to treat my child for any eye-related care if I am not present. I agree to pay for any and all services/products at the time of this eye exam if I do not have insurance or if it is not valid per prior authorization. If insurance is valid, I will pay the difference the insurance does not pay. We do not accept all insurance assignments. ALWAYS ask the receptionist if we are a Provider for your Vision and/or Medical insurance. Payment is required for all non-covered and/or deductible services and items.
Patient or legal guardian/parent signature*
Today's Date*

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Reason?*
Preferred Date/Time*
New Or Returning?*
New patient
Returning
Name*
First Last
Confirm*
By Phone
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Phone*
Best Time to be Reached for Confirmation*

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Email*

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Estrella Mountain Eye Care PLLC

13065 West McDowell Rd Ste. B-105
Avondale, AZ 85392

Phone: 623-845-1400
Fax: 623-845-1401
Email: emec2020@gmail.com
(Do not send personal health information by email.)

Monday: 8:30 AM - 5:00 PM
Tuesday: 8:30 AM - 5:30 PM
Wednesday: 8:30 AM - 12:00 PM
1:00 PM - 5:30 PM
Thursday: 8:30 AM - 5:30 PM
Friday: 8:30 AM - 5:00 PM
Saturday: Closed
Sunday: Closed

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Contact Us
What’s New + Our Blog
AOA Privacy Policy
Disclaimer
Site Map

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Estrella Mountain Eye Care, PLLC - Located at 13065 West McDowell Rd Ste B-105, Avondale, AZ, 85392. Phone: 623-845-1400. https://www.estrellaeyecare.com/

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