Premier Eye Care - Preregister Online

Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email Address:
Date of Birth:
Social Security #:
Insurance Company/Group/ID#:
Emergency Contact Person:
Relationship:
Emergency Contact Telephone:

I would like to be contacted for an appointment.
Yes	No ( Not at this time. I will call your office at my convenience.)

I would like my appointment confirmed the day prior to my visit by
Telephone	E-mail

I request a free LASIK screening and have completed the registration above.
Yes (we will call you to set up a convenient time)	No Not at this time, but add me to your mailing list.

**Please bring your insurance card with you to your appointment if you would like for us to file your insurance claim.

Pre-Register Online!