Get Joslin & Joslin Eye Center Patient Registration

Filling out the Joslin & Joslin Eye Center Patient Registration form online is an essential step in accessing your eyecare services. This guide is designed to provide you with clear instructions on how to complete each section of the form accurately and efficiently.

Follow the steps to complete your patient registration seamlessly.

1. Press the ‘Get Form’ button to acquire the registration form. This will open the document in your preferred editing application.
2. Begin with the patient section: Input your full name, date, address, home phone, cell phone, birthdate, email, employer, and who referred you to the clinic.
3. Next, provide your age, sex (indicate M for male, F for female), and your social security number. Specify your race by selecting from the listed options.
4. Fill in your city, state, and zip code. Next, complete the emergency contact section by providing the name, relationship, and contact numbers of your emergency contact.
5. In the financial responsibility section, clarify who is responsible for the account and their relationship to you. Include their birthdate and social security number.
6. Sign and date the responsible party acknowledgment, confirming the understanding of financial responsibilities.
7. For the assignment and release section, authorize Joslin Eye Center to process insurance benefits for your services by signing and dating the form.
8. Read and sign the acknowledgment of receipt of the notice of privacy practices, ensuring you understand your rights.
9. Complete the medical history questionnaire on the second page, detailing past personal history, medications, drug allergies, and eye care history.
10. Fill out the family and social history sections, noting any relevant diseases, substance use, and symptoms. Ensure you provide detailed information as necessary.
11. Conclude the form by checking any current symptoms in the review of systems section. Provide a list of any other conditions not previously mentioned.
12. Lastly, sign and date at the bottom of the form to affirm the accuracy of the information provided. You can then save your changes, download, print, or share the completed form as required.

Start filling out your Joslin & Joslin Eye Center Patient Registration online now!