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EASY ACCESS TO CARE

State Street Optics Patient Forms

Completing your forms ahead of your visit can help make your check-in faster and more convenient. Our patient forms are easy to access and allow you to provide important information before you arrive, so we can focus on your care during your appointment.

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BEFORE YOU BEGIN

Online Registration Hub

To provide the highest standard of eye care, we require all new and returning patients to update their information annually. Please have your insurance cards and a list of current medications ready.

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

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Date *

Standard Of Care

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NEED HELP?

Questions about your visit?

If you have any questions while completing your forms or need assistance before your visit, our team is here to help. Give us a call, and we’ll be happy to guide you through the process so everything is ready for your appointment.