Transcription of Commonwealth Eye Care Associates Telephone: …
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Commonwealth Eye Care Associates Telephone: …
Commonwealth Eye care Associates Dr. Andrew J. Michael, Dr. Shawn H. Hobbs, Dr. Joseph D. telephone : (804) 217-6363 Iuorno, Dr. Rick Douglas, Dr. Tami A. Flowers, Dr. Meredith Diehl, Dr. Jonathan Noble PATIENT REGISTRATION, CONSENT TO treatment , AND PAYMENT AUTHORIZATION. PLEASE FILL OUT FORM COMPLETELY & PRINT CLEARLY. NAME_____ BIRTH DATE_____. LAST FIRST MI NICKNAME MONTH DAY YEAR. ADDRESS_____. STREET CITY STATE ZIP. SEX: F M MARITAL STATUS Single Married Divorced Separated Widowed Other RACE: Caucasian/ African American/ American Indian/ Asian Hispanic-Latino/ other _____. ETHNICITY; American/ Mexican/Japanese/Chinese/Asian/European/ Latino/ other_____. PREFERRED LANGUAGE: _____ PATIENT'S SSN _____-_____-_____. EMAIL _____. HOME PHONE _____WORK PHONE_____CELL PHONE_____.
CONSENT: I do hereby voluntarily consent to examination and treatment by COMMONWEALTH EYE CARE ASSOCIATES (the “Practice”) and to the rendering of such care and medical treatment as may be deemed necessary or appropriate by the physicians and other clinical personnel of the Practice.
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