Local Patient Registration Form

LOCAL PATIENT REGISTRATION FORM
Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
National ID Number

Sex
Phone Number *

Area Code Phone Number
Cell Number

Area Code Phone Number
Work Number

Area Code Phone Number
Occupation
Email
example@example.com
Home Address

Street Address

Street Address Line 2

City Country

Postal / Zip Code
Referring Eye Care Specialist
Do you have medical insurance? Yes or No *
Name of Medical Insurance Company
Next of Kin *

Last, First, Middle Telephone
Next of Kin Cell Number
Relation
Next of Kin Email
example@example.com
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 *

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LOCAL PATIENT REGISTRATION FORM