Get Carty Eye Associates Patient Registration

Completing the Carty Eye Associates Patient Registration form online is a straightforward process designed to capture essential information for your visit. This guide will provide you with step-by-step instructions to ensure efficiency and accuracy while filling out the form.

Follow the steps to complete your patient registration form online.

1. Press the ‘Get Form’ button to access the registration form and open it for editing.
2. Begin by filling out your last name, first name, and middle initial in the designated fields.
3. Choose your title from the options provided: Mr., Mrs., Ms., Miss, MD, PhD, Jr., Sr., or Other.
4. In the address section, provide your street address, including any apartment number, city, state, and zip code.
5. Enter your contact numbers in the respective fields for home, work, and cell.
6. Input your email address accurately, as it may be used for communication regarding your appointments.
7. Fill in your Social Security number in the designated format.
8. Indicate your sex by selecting either Male or Female.
9. Select your marital status from the options listed.
10. Specify your employment status by selecting from Full-time, Part-time, or None.
11. Enter your date of birth in the required format.
12. Provide the reason for your visit in the space designated for that purpose.
13. Indicate if your visit is related to a work injury or a motor vehicle accident.
14. Specify whether you currently reside in a Skilled Nursing Facility or are under Hospice care.
15. List the name of the person who referred you to this office, if applicable.
16. Input the name and address of your family doctor.
17. Indicate who is responsible for medical bills by checking the appropriate box.
18. Provide the relevant contact details for the person responsible for the bills.
19. Fill in the emergency contact details, including the person's name and phone number.
20. Under employment information, provide the patient’s employer and job title, followed by the employer’s address and work phone.
21. Next, complete the primary insurance information, including the insurance company name and the insured’s details.
22. If applicable, provide details for secondary insurance information following the same format as above.
23. If you have a vision plan, indicate that as well.
24. Review the payment authorization statement, and sign the form, including the date. If you are signing on behalf of a minor, indicate your relationship.
25. Once all sections are completed, save your changes, and choose to download, print, or share the form as necessary.

Start filling out your Carty Eye Associates Patient Registration form online today!