www.eyeboston.com 		Ophthalmic Consultants of Boston
50 Staniford Street • Boston, MA 02114
617.367.4800 • Toll Free 800.635.0489
Boston • West Yarmouth • Sandwich • Waltham • Beverly • Brookline • Stoneham
Please complete and return this form to the front desk on the day of your appointment. Please bring all insurance forms, insurance cards and insurance referrals on the day of your appointment.

Please note: the information sent through this form is not encrypted or sent through a secure server.

My Appointment is on   at   with
PATIENT INFORMATION
Today's Date:
Name: (first, middle, last)       
Address:
City:     State:     Zip:
Date of Birth:     Age:     Sex:
Marital Status:     SSN:
Home Phone:   Work Phone:
Nearest relative or friend not living in the same household:
Relationship:     Relative/Friend's Phone:

If the patient is a minor, please provide the following information:
Father's Name:     Mother's Name:
Father's Employer and Work Phone:
Mother's Employer and Work Phone:
EMPLOYMENT INFORMATION
Employer:
Address:
Phone:
PRIMARY CARE PHYSICIAN
Primary Care Physician or Pediatrician:
Address:     Phone:
REFERRAL SOURCE (if different from Primary Care Physician)
Referring Physician:     Phone:
Name and relationship of referral if other than physician:
Address:
INSURANCE INFORMATION
Primary Insurance:
Name of Policyholder:     SSN:
Policy Number:     Group Number:

Secondary Insurance:
Name of Policyholder:     SSN:
Policy Number:     Group Number:

Worker's Compensation:     Industrial Injury?     Automobile Injury?
Other? (please explain)
Company (for worker's comp):
I hereby authorize the release of any information necessary to process claims for any and all professional services rendered by Ophthalmic Consultants of Boston to me and my dependents.

I authorize the payment of any benefits due to Ophthalmic Consultants of Boston.

I understand that I am responsible for obtaining an insurance referral if my insurance carrier requires one. If not, I will be responsible for payment. I also understand that I am responsible for payment on services not covered by my insurance company.


SIGN HERE:________________________________________________ DATE:______________

Please email this form to Ophthalmic Consultants of Boston.
Please create a form which I can print out and bring to my appointment.