Sabates Eye Centers - New Patient Registration

Please complete the information below. Prior to hitting the submit button, please print this page for your records.

For emergency or time sensitive matters, please call us direct at 913-261-2020 or toll free at 1-800-742-0020.

	* Required
Date:
* Patient First Name:
* Patient Last Name:	Sex: M F
Email Address:
Street Address:
City, State, Zip:	,
* Date of Birth:	* Phone Number
Marital Status:	Single Married Divorced Widowed
Preferred Office Location:
Referring Doctor:
Address of Referring Doctor:
Spouse or Nearest Relative:
Phone Number:	Relationship:
Person Responsible for Bill:
Address:
Employer:	Phone Number:
Insurance Information (View Participating Insurance Plans)
Primary Insurance Company:
Policy Holder:
Relationship to Patient:
Mail Claims To: (Address)
Insurance Phone Number:	Policy #
Secondary Insurance Company:
Policy Holder:
Relationship to Patient:
Mail Claims To: (Address)
Insurance Phone Number:	Policy #

*Type password shown below: