Patient Registration Form

Name: Long Beach Family Optometry
Address: 6332 E. Spring Street, Long Beach, CA, 90815, US
Telephone: 562-421-4488
Price range: $000 - $300

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
Patient Information
Name*
Prefix First Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Alternate Phone
Email Address*

Please provide us your email address.
Personal Information
Gender*
- Female
- Male
Date of Birth*
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Preferred Language*
Race*
Ethnicity*
Marital Status
Marital Status - Other

Please provide your marital status.
Employment Status
Employment Status - Other

Please provide your employment status.
Employer
Occupation
How were you referred to our office?
Referral Status - Other

Please let us know how you were referred to our office.
Communication Preference
We utilize text messaging to confirm your appointment and to notify you when your glasses or contacts are ready.
- Yes
- No
Primary Insurance
Please bring all insurance cards with you to your appointment.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Secondary Insurance
Do you have secondary insurance?
- Yes
- No
If you have coverage through another plan/organization, please fill in the details below.
Insurance Company Name
Insurance Company Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insured's Name
First Last
Identification Number
Group Number
Insured's Date of Birth
MM slash DD slash YYYY
Patient's Relation to Insured
Comments
If you have any comments you would like to add, please enter them here.
Privacy Policy
Health Information Protection*
- I have read and agree to the Privacy Policy
Signature*
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Phone
This field is for validation purposes and should be left unchanged.

Patient Information

Personal Information

Primary Insurance

Secondary Insurance

Comments

Privacy Policy

Long Beach Family Optometry