Demographics

PLEASE PRINT

PATIENT:

Last Name: ______________________  First Name:__________________Mid. In________

                    Dr  /  Mr  /  Ms  /  Miss  /  Mrs (circle one)

Date of Birth: ___________________________                    Sex: M  F

Marital Status:         Single             Married            Divorced/Widow(er)              

Home Address_____________________________________________________________              Apt#:  ________

City: ___________________________ State: _________ Zip Code: ________________

Home Phone: (_____) ______-________  Cell Phone: (_____) - ______ - ________ 

Social Security #:______ --- _______ --- _______ 

 

Occupation: _____________________________________ Retired: Yes           No             

Work Phone #: (______) _____ - __________   

Present Employer: __________________________________

Employer’s Address: ________________________________________________________________________

Referred By: ___________________________________________________________

Name of Family Physician: ________________________ Phone#: (____) ______-_______

Physician’s Address: _______________________________________________________________________

Optometrist: ___________________________ Phone#: (_____) _______ - ____________

Name of Spouse/Parent: ______________________Date of Birth: ___________________

Spouse’s Employer: _________________________________________ Retired: Yes      No                                        

PRIMARY INSURANCE:

Insurance Name: ___________________________________________________________

ID#: _________________________________ Group #_______________________

Subscriber's Name (if different from patient): _____________________________________________________

Relationship to Patient:          Self    Spouse     Child    Other (check one)

Subscriber’s Address (If Different from patient): ___________________________________________________________________

Subscriber’s Date of Birth: ________________

Subscriber’s Social Security#: ________---________---_________  

Phone#: _______________________________

Retired:    Yes   No

SECONDARY INSURANCE:

Insurance Name: __________________________________________________

ID#: ________________________________Group#:  _____________________

Subscriber's Name (if different from patient): _____________________________________________________

Relationship to Patient:       Self        Spouse      Child     Other (check one)

Subscriber’s Address (If Different from patient): ____________________________________________________________________

Subscriber’s Date of Birth: ______________________

Subscriber’s Social Security#: ________---________---_________ 

Phone#: _______________________________

Retired:     Yes    No

PATIENT OR AUTHORIZED SIGNATURE:

ALL INSURANCE: I authorize the release of any medical information necessary to process this claim and request payment of benefits to Bannett Eye Centers.  I understand I am financially responsible for all fees and will be billed for any balance & deductible my insurance does not cover.

X______________________________________________________________

Date: ______________________________

MEDICARE ONLY: I request payment of authorized Medicare benefits be made to Bannett Eye Centers. for any services furnished me by that physician.  I authorize any holder of medical information about me be released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

X______________________________________________________________

Date: _______________________________

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Latest comments

06.12 | 17:36

Dr. Della Torre is wonderful. Listen to my concerns and immediately ordered MRI. I didn't feel rushed.

...
23.08 | 18:32

Dr Torre is a great doctor. She would listen to our questions and will find answers and make recommendations. It makes us feel that she cares about her patience

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23.07 | 03:15

I am a fairly new patient of Dr. Bannett's. But, in a short period of time I found him to be extremely professional, thorough and knowledgable.

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27.06 | 13:54
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