Patient Information First Name*Last Name*Date of Birth* MM DD YYYY Phone*Email Your email address will not be used for solicitation, or sold or shared with a third party.Preferred Contact MethodPhoneEmailAddressDo you wear Contacts?*YesNoInsurance InformationOccupationEmployerIs your visit due to a workplace injury?*YesNoPrimary Care PhysicianWhich applies?*Select OneI have routine vision coverage through my medical plan.I have a separate vision plan.I do NOT have vision coverage through my medical plan OR a separate vision plan.Primary Insurance*Primary Insurance ID #*Secondary InsuranceSecondary Insurance ID #Does your insurance require a referral?*YesNoI don't knowReferral SourceReason for visitFinancial Policies* I acknowledge I have read and understand the Financial Policies below: Your insurance plan determines your copay/coinsurance/deductible. Contact your insurance company to obtain co-pay, coinsurance/deductible information. All co-payments are due at the time of service. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for payment of the services. Please notify our office of any change to your insurance coverage. We kindly request a 24 hour notice to either cancel or reschedule an appointment. You may be charged a $25 fee if you do not provide 24 hour notice. Just as we make every effort to accommodate you for your eye care, we expect that you will make every effort to pay your bill promptly within 30 days. If you have a financial hardship or if you are unable to pay your bill in its entirety, please contact our billing office to discuss payment options.Tell Us A Little MoreIs there anything else you'd like us to know?How did you hear about Spector Eye Care?*Select OnePatientPhysicianInternet SearchRadioSocial MediaOtherToday's Date* Date Format: MM slash DD slash YYYY Upload completed formsAccepted file types: pdf, jpg, png.