Patient Forms
Insurance
Careers
Book Appointment

Thanks for contacting us! We will get in touch with you shortly.

Please Present all Insurance Cards
Patient Name *
Today's Date *
Date of Birth *
*
Sex *
Address *
*
*

Emergency Contact Information and Authorization for Disclosure of Medical Information

I authorize The Optics Group to disclose my protected health information (PHI) and/or contact the following individual(s) in the event of an emergency or for purposes regarding my clinical care, billing, or appointment coordination:

Contact 1 Emergency Contact?
Contact 1 Authorized to make Medical Decisions?
Contact 2 Emergency Contact?
Contact 2 Authorized to make Medical Decisions?

The following section is required if you are not the primary insurance policyholder. Please complete all fields below.

Policy holder's Date of Birth
Policy holder's Address
Policy holder's Date of Birth
Policy holder's Address

Our Standard of Care policy is located at the bottom of this page.

By signing below, I acknowledge that I have read and understood the Standard of Care policy and the information above, and that I have had the opportunity to ask questions. 

*
Date *