Patient Information Form "*" indicates required fields Please enter as much information as possible and we will call or email you to confirm your appointment. If you are using insurance that requires forms or vouchers, all forms needed must be in your posession before you schedule an appointment. If no forms are required we will verify your eligibility online. To pick up eyeglasses or for simple repairs please do not fill out this form. Call the location and they will help you to find an appropriate time to enter one of our locations . This form is HIPPA compliant and your confidential information is protected. Patient InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Address* Street 1 Street 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Home Phone NumberCell Phone Number*Date of Birth* Month Day Year DateEmail* example@example.comLocation and ServicesAt which Specs for Less location are you looking to schedule an appointment?* Forest Avenue - Staten Island Veterans Road West - Staten Island Richmond Avenue - Staten Island Keyport - New Jersey 3rd Avenue - Manhattan What services are you looking to come in for?* Eyeglass Exam DMV Exam Contact Lens Exam & Fitting Pick out new eyeglasses. I already have a prescription. Primary InsuranceWill you be using an insurance plan?* Yes No What is the name of the insurance or Union plan you are using? If you are not using insurance please type "none"What is your insurance ID#?The vision insurance plan is: A personal plan I'm covered under my spouse's plan I'm covered under my parent's plan Other Enter the last 4 digits of your Social Security #last 4 digits onlyEnter the last 4 digits of your spouse's or covered parent's Social Security #last 4 digits onlySpoue or Parent Date of Birth Month Day Year Only necessary if you are covered under someone elses plan.Can you upload a picture of your insurance card? Yes, I can upload my existing file from this device No, I do not have it right now Please attach a picture of your insurance ID card or optical voucherMax. file size: 31 MB.Sign and DateSignature*Date* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
