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We Can Change The Way You See Your World!

Please fill out and submit this form to learn more about MidWest EyeCenter and receive an
e-brochure on either Premium Lenses, Cataract Surgery or Laser Vision Correction.

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Our Locations

East: Eastgate Professional Building
Suite 305
4452 Eastgate Blvd
Cincinnati, OH 45245
513.752.5700 Map It
West: 6779 Colerain Ave.
Cincinnati, OH 45239
513.741.1313 Map It
North: 8760 Union Centre Blvd.
West Chester, OH 45069
513.454.0544 Map It
South: 7510 US Route 42
Florence, KY 41042
859.525.6215 Map It

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Patient Registration Form

Either fill out this online form below, or download and fill out the Registration Form (PDF), and bring it with you on your next visit with us.

Patient's Last Name*

Patient's First Name*

Patient's Middle Initial

Patient's Sex

Male

Female

Patient's Age

Who was your previous eye care provider?

Patient's Date of Birth

How did you learn about us?

Patient's SS#

Is there someone we can thank for referring you to us?

Guarantor, if applicable

Patient's relationship to guarantor

Guarantor's SS#

Guarantor's Date of Birth

Home Address (if different than patient)

State

Zip Code

City

Work Phone

Home Phone

Patient's Address

Patient's Work Phone

Patient's City

Patient's State

Patient's Occupation

Patient's Zip Code

Patient's Home Phone

Employer Name

Email Address

Employed

Fulltime

Part Time

College Student

Yes

Full Time

Part Time

Emergency Contact and Phone #

Patient's Marital Status

single

married

widowed

divorced

Primary Insurance Information

Company Name

Address

City

State

Zip Code

Subscriber's Name

Subscriber's DOB/SS#

Certificate or ID#

Policy #

Group #

Secondary Insurance Information

Company Name

Address

City

State

Zip Code

Subscriber's Name

Subscriber's DOB/SS#

Certificate or ID#

Policy #

Group #

RELEASE OF INFORMATION CLAIM PAYMENT AUTHORIZATION

I hereby give consent to the attending physician to release any information acquired in the course of examination or treatment andallow a photocopy of my signature to be used for insurance purposes only. I give permission to release medical records or information to other medical doctors.

The subscriber hereby gives consent for his/her insurance company(s) at its option to issue indemnity checks to the provider rendering services.

Date

SIGNATURE OF PATIENT

I received a copy of the MidWest EyeCenter/MidWest Eye Surgery Center's Notice of Privacy Practices. (HIPAA regulation requirement); Patient's Rights & Responsibilities, Advance Directives Policy & Financial Disclosure (Medicare's Conditions of Coverage requirement).

Date

SIGNATURE OF PATIENT

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Disclaimer: This site contains information about eye surgery and procedures related to eye care. It is not to be taken as medical advice.