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The Eye Center

Medical & Surgical Eye Care
Laura Muller, M.D.

Name: LAST FIRST Middle

Social Security #: - - Birth Date: / / Sex: M F

Address: Apt/Unit #:

City: State: Zip:

Home Phone # ( ) - Cell Phone # ( ) - 
Single  Married  Divorced  Separated  Widowed  Long Term Partner
*listed below are categories required by federal government:
Race:  American Indian,  Asian,  African American,  Native Hawaiian or  White
Ethnicity:  Hispanic or  Not Hispanic Preferred language  English  other:
Name of Primary Care Physician:

Are you employed?  Yes  NO If Yes, Name of Employer:

Employer Work # ( ) - If NO, Are YOU Disabled?  Yes  NO
Name of Primary Name of Secondary
Insurance: Insurance:

Policy #: Policy #:

Group #: Group #:

Are YOU the Policyholder?  Yes  NO Are YOU the Policyholder?  Yes  NO

If NO, Policyholder’s SS#: - - If NO, Policyholder’s SS#: - -

Policyholder’s Name: Policyholder’s Name:

Policyholder’s DOB: / / Policyholder’s DOB: / /

Policyholder’s Relationship to Patient: Policyholder’s Relationship to Patient:

Spouse / Child / Other: Spouse / Child / Other:

*******Do you live at another address for any part of the year?  YES  NO *******
If YES, please provide us with a secondary address & phone number:

Address: Apt/Unit #:

City/State/Zip: Phone #: ( ) -

What months do you reside at this address listed above?

By completing this form, you are stating that the written information provided, to the best of your knowledge, is
true and correct.

Signature: Date:
POS® Reorder # 1422345