Your Eye Doc-Dr. Tahir: Online Scheduler - Register

Patient Registration

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Please enter Home or Cell Number

Patient First Name * Please enter First Name

Patient Last Name * Please enter Last Name

Last 4 Digits of your SSN * Please enter Last 4 Digits of SSN

Home Phone

Mobile Phone *

Work Phone

Email * Please enter Email

Patient Gender *

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Patient Birthdate *

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User Name * Please enter User Name

Password * Please enter Password

Confirm Password * Please enter Confirm Pasword The Password and Confirmation Password must match*

Do you have MEDICAL insurance?:

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Insurance Policy Holder (if applicable):

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Spouse

Parent

Name of Insurance:

Date of Birth of Policy Holder:

Name of Policy Holder:

Last 4 digits of SSN of Policy Holder:

Do you have VISION insurance?:

No

Yes

Insurance Policy Holder (if applicable):

Self

Spouse

Parent

Name of Insurance:

Name of Policy Holder:

Date of Birth of Policy Holder:

Last 4 digits of SSN of Policy Holder:

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