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Available Forms

Welcome To Our Office Form

Welcome To Our Office

Welcome to Broome Family Eye Care. Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please complete the following form to ensure that the information we have is current and accurate. If you have any questions, please do not hesitate to ask. Thank You!

We provide our patients the option to participate in our online patient communication system. Please choose yes or no for each option.

In order to control the cost of billing, we ask that the patient's portion of the bill be paid at the time services are rendered or materials ordered. If vision or medical insurance is to be filed, then all applicable co-pays, deductibles, and non-covered services are the responsibility of the patient and due at the time of the service and ordering of the materials.

Payment from my insurance is to be paid to Broome Family Eye Care. I understand that the insurance I listed above will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not guarantee of payment by my insurance company and that the final determination can only be made when the claim is processed.
Print first and last name of Patient/Guardian
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