Title     Mr Mrs Miss Ms Dr     First      MI Last                                  

Address  Address 2 

City    State/Zip        

SS #      Format 555-55-5555  Birth Date       Format 55/55/5555

Home Ph.      Work Ph.     X    Cell Ph.      Format 555-555-5555

e-mail   Format  your address@your domain

Employer       Occupation  

Marital    Married Single Domestic Partner

Is this your first visit?    YES NO     If referred, who may we thank

 My Appointment is scheduled on          Location   Embassy Annapolis Anchor Eye Care Annapolis Anchor Eye Care Bethesda               My appointment is for   Glasses Contacts

We welcome your insurance plans which we are providers, it is your responsibility to know what your coverage is prior to your exam. We will bill your carrier for those fees allowed under your plan, however if your plan denies your coverage you will be responsible for all fees, we do not re-bill.

Patients Complete Name                      

Patients Date of Birth                                Format 55/55/55

Patients Social Security Number              Format 555-55-5555

Card Holders Full Name                        

Card Holders Date of Birth                        Format 55/55/55

Card Holders Social Security Number       Format 555-55-5555

Card Holders Insurance ID :                      (please note this may be a unique number from your card or your SS#)

Insurance Type                                        Aetna Avesis CareFirst Davis Vision Aetna Vision One Cigna Other Davis Vision VSP Tricare basic Tricare Prime Tricare for Life Medicare

If Other                                                   

Your Day Time Phone Number                   Format  555-555-5555

Comments                                               

At Embassy Eyecare we take your privacy seriously. We will NEVER share your information with anyone other than your insurance carrier.

Please Note: some carriers require your social security number to process your claim