Overseas Patient Registration Form

OVERSEAS PATIENT REGISTRATION FORM
Name*

First Name Middle NameLast Name
Next of Kin

Last, First, MiddleTelephone
National ID Number
National ID Number
Date of Birth *

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2

CityCountry

Postal / Zip Code
Phone Number*

Area CodePhone Number
Cell Number

Area CodePhone Number
Work Number

Area CodePhone Number
Intended Address in Barbados

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Email
example@example.com
Referring Eye Care Specialist
Flight Information
Airline, Flight No.
Travel Date From

MonthDayYear
Date
Travel Date to

MonthDayYear
Date
Do you have medical insurance? Yes or No*
Patient Financial Obligation Agreement

I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to MAR-NIG MANAGEMENT LTD / DR. NIGEL BARKER for services rendered. I authorize representatives of Warrens Eye Care Centre to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.
Do you agree to the Financial Obligation Agreement *

OVERSEAS PATIENT REGISTRATION FORM