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Iworks Team
Patrick L. Spencer,D.O.
Staff
Testimonials
Cataracts
What is a Cataract
Traditional Cataract Surgery
Laser Cataract Surgery
Frequently Asked Questions
Lasik
ALL Laser Lasik Surgery
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What’s New!
Dextenza Insert Replaces Drops!
Eyelid “Uplift” with Upneeq
Our Office
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Our Technology
3D Wavescanner
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Astigmatism
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Cataracts
Conjunctival Problems
Corneal Disorders
Diabetic Retinopathy
Dry Eyes
Episcleritis and Scleritis
Eye Strain
Flashes and Floaters
Glaucoma
Hyperopia
Macular Degeneration ARMD
Retinal Disorders
My Visit Info
Patient Forms
Patient Sign-In
CareCredit Financing
Registration Form
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download our printable forms here
Basic Information
Marital Status
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First Name
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Date Of Birth
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Age
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Sex
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Home Phone
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Appointment Confirmation Preference
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Billing Information
Insurance Policy Holder
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First Name Of Policy Holder
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Middle Initial
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Last Name
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Date Of Birth
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Street
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Zip Code
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Relationship To Patient
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Social Security Number (Of Policy Holder)
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Employer
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Position
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Name Of Emergency Contact Not Living At Home
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Emergency Contact's Phone Number
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Emergency Contact's Relationship To You
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Who Referred You Here
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Do you have a primary family physician?
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Family Physician's Name
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Family Physician's Address
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Family Physician's City
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Family Physician's State
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Family Physician's ZIP Code
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I hereby authorize that my insurance benefits be paid directly to Patrick L. Spencer, D.O., Inc. or any covered services provided by him or his assistants. I also authorize him to release to my insurance company any necessary information. I understand that I will be responsible for any and all expenses that are not covered by my insurance that occur during my care and I will pay my account in a timely manner.
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