Patient Welcome Form

Welcome Form

Step 1 of 5

Patient Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email*
Gender/Sex
- Male
- Female
Patient/Guardian Name

If patient is a minor
Date of Birth
MM slash DD slash YYYY
Social Security Number
Occupation
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone
Spouse's Name
First Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Spouse's Occupation
Spouse's Employer
Spouse's Employer Phone
Preferred Location
- Longview Office
- Woodland Office
Whom may we thank for referring you?
First Last

Phone Numbers and Emergency Contact
Home Phone
Cell Phone
Work Phone
Best time and place to reach you?
IN CASE OF EMERGENCY, CONTACT
First Last
Specify someone outside of your household
Relationship to you
Contact's Home Phone Number
Contact's Work Phone Number
Insurance Information
PLEASE NOTE: A DEPOSIT OF HALF THE TOTAL FEE IS REQUIRED TO ORDER MATERIALS, THE OTHER HALF IS DUE UPON DELIVERY.
Primary Insurance Subscriber
First Last
Social Security Number
Relationship to patient:
- Self
- Spouse
- Parent
Subscriber Date of Birth
MM slash DD slash YYYY
Vision Plan Name:
ID #:
Medical Plan Name:
ID #:
Secondary Insurance Subscriber
First Last
Social Security Number
Relation to patient:
- Self
- Spouse
- Parent
Subscriber Date of Birth
MM slash DD slash YYYY
Vision Plan Name:
ID #:
Medical Plan Name:
ID #:

Medications and Allergies
List medications you are currently taking, including eye drops:
Pharmacy Name:
Pharmacy Phone Number
List your allergies to medications or other substances:
Financial Arrangements
Longview Eye and Vision will bill your insurance as a courtesy if compete insurance information is provided. In order to submit a claim to your insurance company we will need authorization to release medical information to your insurance company.
I authorize any medical information necessary to process my claims and request payment be issued to Longview Eye and Vision. I understand that if my insurance does not pay I am responsible for the bill. I also understand that if I carry no insurance I am responsible for the whole bill at time of service.
A service charge of 1.00% per month will be added after 60 days. This is an APR of 12.00%. Our minimum service charge is $1.00. All NSF checks are subject to a fee of $35.00. Any account going to the collection process will be assessed a fee of $35.00. In the even legal action should become necessary to collect any unpaid balance due to medical services rendered to me or my family, I/we agree to pay reasonable attorney fees or other such costs as the court determines proper. I agree that the venue for any legal action shall be in Cowlitz County.
To avoid misunderstandings, we are always happy to discuss questions you have regarding our financial policies.
PLELASE NOTE: A DEPOSIT OF HALF THE TOTAL FEE IS REQUIRED TO ORDER MATERIALS, THE OTHER HALF IS DUE UPON DELIVERY.
By entering your name here digitally, you agree to the financial policies stated above.
First Last
Date
MM slash DD slash YYYY
Acknowledgement of Receipt of Privacy Policies
I acknowledge that I received a copy of the Notice of Privacy Practices for this office.
First Last
Date
MM slash DD slash YYYY

Longview Office Hours

Monday
8:00am - 5:30pm

Tuesday
8:00am - 5:30pm

Wednesday
8:00am - 5:30pm

Thursday
8:00am - 5:30pm

Friday
8:00am - 5:30pm

Saturday
Closed

Sunday
Closed

Cathlamet Office Hours

Woodland Office Hours

Monday
8:30am - 5:30am

Tuesday
Closed

Wednesday
8:30am - 5:30pm

Thursday
8:30am - 5:30pm

Friday
8:30am - 5:30pm

Saturday
Closed

Sunday
Closed

Patient Welcome Form

Welcome Form

Step 1 of 5

Patient Information

Eye Health History

Phone Numbers and Emergency Contact

Insurance Information

Health History

Social and Family History

Medications and Allergies

Financial Arrangements

Acknowledgement of Receipt of Privacy Policies

Longview Office Hours

Cathlamet Office Hours

Woodland Office Hours