*First Name:

*Last Name:

Middle Initial:

*Street Address:

*City, State, Zip:

*Phone Number:
If you have no phone #, put "none."

*E-mail:
A copy of your registration will be sent to your E-mail.

*Sex: Male Female

*Birthday:
Use MM-DD-YYYY format.

Social Security #:
All information is held in strict confidence and is secure.

Reason for Exam:

*Are you using Insurance? No Yes

Name of Insurance or Vision Plan: Advantra Medicare Avesis Dauphin Precision Tool Davis Vision EyeMed Gateway Geisinger Health America/ Assurance Highmark Blue Shield Humana Medicaid ACCESS Medicare NCAS NVA OptiCare PA Blue Cross PA Blue Shield Railroad Medicare National Beef Packing Ritz Craft Safety Voucher SecureHorizons Direct Spectera OptumHealth Sterling Option Superior Vision Services Today's Options Medicare Unicare Aetna US Healthcare Wellcare Medicare
Hold down Control or CMD key to select multiple insurances.

Insurance Identification/ Suscriber #:

Eye History: Cataracts Glaucoma Eye Surgery Eye Injury

Health History- please select if you have any of the following medical conditions: Diabetes High Blood Pressure High Cholesterol Lung Disease
Hold down Control or CMD key to select multiple insurances.

Medications- please list any current medications being taken:

*Do you wear Contact Lenses? No Yes

*Are you interested in Contact Lenses? No Yes

Insurance Authorization: By checking this box I authorize Geist Optometry to submit insurance claims on my behalf and electronically sign to do so. Yes No

Privacy Rights: I have read and/ or downloaded the Patient Privacy Rights in the Dowloads section. Yes No

*Required