New Patient Registration

For an appointment, please call 800-731-3937 and let us know which of our three locations (Camp Hill, PA and Harrisburg, PA) is best for you. To register with Premier Eye Care Group please complete the form below.

Fields in Red are required fields.

First/Middle Initial/Last Patient Name Mr. Ms. Mrs. Miss Patient SS#: Home Address: City: State:Select StateAlabama Alaska Arizona Arkansas California Colorado Connecticut Dist.Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Labrador Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Zip Code:   Phone (H): (xxx)xxx-xxxx Phone (W): (xxx)xxx-xxxx Email Address: Age: Sex: Date of Birth: (mm/dd/yyyy)   Employer: Occupation: Emergency Contacts Spouse/Parent: First/Middle Initial/Last   Phone(H): (xxx)xxx-xxxx Phone(W): (xxx)xxx-xxxx Other: First/Middle Initial/Last   Phone(H): (xxx)xxx-xxxx Phone(W): (xxx)xxx-xxxx Have you had any of the following:   Does anyone in your family have: High Blood Pressure Heart Disease Arthritis Diabetes Other   Cataracts Glaucoma Diabetes Blindness Other Current Medications: Allergies: Primary Care Physician: PCP Phone#: (xxx)xxx-xxxx Who may we thank for your referral? Do you have any vision insurance? YES NO Do you have any medical insurance? YES NO Subscribers Name: First/Middle Initial/Last DOB (mm/dd/yyyy): Employer: For Workmans Comp or Motor Vehicle Claims, please give all necessary claim information to our staff. Financial responsibility beyond insurance and for minor children - complete the following: Name: First/Middle Initial/Last Relationship: Phone(H): (xxx)xxx-xxxx Phone(W): (xxx)xxx-xxxx Address: DOB (mm/dd/yyyy): SS#: Assignments of Benefits: "I request that payment of authorized Medicare/Medicade and/or Insurance Co. Name benefits be made either to me or on behalf of Premier Eye Care Group, Inc. for any services furnished me by their physician. I authorize the release of any medical information needed to determine these benefits or benefits payable to related services to the Health Care Financing Administration and its agents, Medicade and/or Insurance Co. Name." Which of our offices do you plan to visit? 92 Tuscarora St. Harrisburg 232-0843 2745 North Front St. Harrisburg 238-6757 1524 Cedar Cliff Dr. Camp Hill 761-3077 Would you like us to contact you to schedule an exam? Yes No Click the "Send" button to complete the form.