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* Mr.Mrs.MissMs.Dr.Rev. Prefix First M.I. Last Today's Date* Date Format: MM slash DD slash YYYY GenderMaleFemaleBirthdate* MM DD YYYY Social Security NumberNicknameMarital StatusSingleMarriedWidowedDivorcedEmployment Status Student Retired Self-Employed Full-Time Part-Time EmployerOccupationHome Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Email Address OK to text?*YesNoEmails and Texts are used to communicate with you for appointment confirmations, updates, etc.Is patient a minor?*YesNoParent 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?*YesNoReferred by Patient Professional PLEASE CHECK OFF ONLY ONE IN EACH OF THE FOUR CATEGORIES BELOW:LanguageEnglishSpanishRaceAmerican Indian or Alaskan NativeAsianHispanicWhiteBlack or African AmericanEuropeanNative Hawaiian or OtherEthnicityNot Hispanic or LatinoHispanic or LatinoNative Hawaiian or Other Pacific IslanderCommunication PreferenceTelephoneEmailPostalTextNOTE: All Patient information is kept strictly confidential. Your information is NEVER shared.INSURANCE INFORMATIONMEDICAL AND VISION Please fill out completely. If there is nothing to list, write “N/A” (not applicable).VISION INSURANCE*VSPVCPVCDEYEMEDMERITAINSelf PayPrimary Member* Name MEMBER ID Patient's Relationship to Primary Member*SelfSpouseChildDate 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?*YesNoName of Primary Medical Insurance*Primary Member* Name Member ID Member SSN Patient's Relationship to Primary Member*SelfSpouseChildDate of birth* MM DD YYYY EmployerGroup #Do you have secondary insurance?*YesNoName of Secondary Medical Insurance*Primary Member* Name Member ID Member SSN Patient's Relationship to Primary Member*SelfSpouseChildDate of birth* MM DD YYYY EmployerGroup #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* Date Format: MM slash DD slash YYYY