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Pre-Appointment
1
Welcome to Closer Look Eyecare, Inc.
Dr. Lori A.
Sanger
Independent Optometrist
Next to the Walmart Vision Center at C-470 & Bowles
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2
Patient Information
*
This field is required.
First Name
Last Name
Address
City
Cell/Mobile phone number
Email
State
Zip
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3
Patient Date of Birth
*
This field is required.
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4
DOB
/
Date
Month
Day
Year
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5
Current Date
-
Date
Year
Month
Day
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6
Age
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7
Parent Information (Patient is a minor)
*
This field is required.
Name
Email
Cell Number
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8
Patient’s Vision Insurance Information
Please choose the vision insurance plan you will be using for this appointment. If not listed here, it is either a plan that is currently not accepted at this location or is not a vision plan. If unsure, please contact your company’s HR department or call the Customer Service phone number on your health insurance card for the name of the correct vision insurance plan. This information is needed to book and to hold your appointment, so please ensure accurate information is provided. Please note that if “No Insurance” is chosen, payment is expected in full at the time of service and an itemized receipt can be generated for you to submit to your insurance on your own behalf.
Please Select
No Insurance (Skip the fields below)
Davis Vision
Medicaid
Spectera
Superior Vision
Vision Service Plan (VSP)
Please Select
Please Select
No Insurance (Skip the fields below)
Davis Vision
Medicaid
Spectera
Superior Vision
Vision Service Plan (VSP)
Please choose No Insurance or Name of Vision Insurance
Please Select
Self
Spouse
Dependent
Please Select
Please Select
Self
Spouse
Dependent
Patient's Relationship to Subscriber
Subscriber’s Formal Name (No nickname)
Subscriber’s last 4 digits of social security number
Subscriber's Date of Birth
Subscriber’s Member ID
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