Patient Registration Form

Thank you for choosing our practice for your eye care needs. In order to serve you properly; please take a moment to complete the form below. If you have any questions please do not hesitate to ask for assistance.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Please ensure that you complete all required fields and that you are directed to the Thank you screen to confirm a successful submission.

In striving to provide the best, most comprehensive eye care and optical services at a reasonable cost, we appreciate your paying in full at the time of your visit. All insurance deductibles and co-pays are to be paid at the time of your visit.

I authorize Smoke Vision Care to release any information including the diagnosis and records of any treatment or examination rendered to me or my dependent to third party payers and/or health care practitioners. I authorize and request my insurance company to pay directly to Smoke Vision Care insurance benefits otherwise payable to me. I understand phone verification and authorization does not guarantee coverage or the covered amount verbally quoted by the insurance company. I understand that although Smoke Vision Care does it’s best to help be estimate what these benefits will be, actual reimbursement amount may differ. In the event of denial of payment or non-coverage for my visit by my insurance company, I agree to be responsible for payment of all services rendered.