Patient Registration Form

Please help us provide the highest level of service by completing the information below. Thank you for choosing our office for all your eye care needs! Please print legibly:

General Information

Date

Name

First Last

Date of Birth

Sex

Male
Female

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

SS#

Occupation

Employer

Driver's License #

Expiry Date

Emergency Contact

Phone

Is there someone special we may thank for referring you to our office?

Other referral source

Phone Book
Insurance
Advertisement

Vision and Health Insurance Information

Do you have insurance that covers eye care?

Yes
No

Vision Insurance Name

ID #

Medicare?

Yes
No

Medicare #

Other health insurance?

Yes
No

Insurance Carrier

Primary Medical Physician

Who is responsible for paying for your eye care expenses that are not covered by insurance?

Self
Other

If other, name of person responsible for paying your eye care expenses

Relationship

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Signature

Important Notice: We are pleased to announce that Dr. Sherman’s practice has been acquired by Tayani Institute as of February 6, 2024. Please visit https://tayani.com

Patient Registration Form

General Information

Vision and Health Insurance Information

Oceanside Office