New Patient Registration

This form is also available for download.

Have you or any member of your family ever been seen by a St Paul Eye Clinic physician before?

Yes

First Name

Middle Initial

Last Name

Birthdate

Street Address

City

State

Zip

Email Address

Home Phone

Work Phone

Mobile Phone

Emergency Contact Name

Phone

Relationship

Primary Care Doctor

Clinic

Name of person(s) authorized to request information regarding my medical care and treatment:

Name

Relationship

Name

Relationship

Full Name

Relationship to Patient

Street Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Please present insurance card to the receptionist on your visit.

Primary Insurance Company

Group Number

Identification Number

Policy Holder Information

Full Name

Birthdate

Social Security Number

Policy Holder Employer

Employer

Work Phone

Street Address

City

State

Zip

If you have secondary insurance, please enter the details below:

Secondary Insurance Company

Group Number

Identification Number

Policyholder Information

Full Name

Birthdate

Social Security Number

Policy Holder Employer

Employer

Work Phone

Street Address

City

State

Zip

Disclaimer: If you register, make an appointment or submit any other information online, all your information is transmitted securely and is held in strictest confidence, adhering to HIPAA guidelines and protecting your privacy.

New Patient Registration

Patient Information

Emergency Contact

Medical Information

Authorized Parties

Party Responsible for Account Payment

Primary Insurance Information

Policy Holder Information

Policy Holder Employer

Secondary Insurance Information

Policyholder Information

Policy Holder Employer