New Patient Registration

Please fill out this form prior to your visit

* Indicates required field

Name *

First

Last

Date of Birth *

Sex *

Nickname *

Last 4 digits of patient SSID *

Primary Language *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell number *

Home number *

Work number *

Email *

Winking Bee Optometry uses e-mail and text for practice communications such as appointment confirmations, reminders and notifications of orders. You are able to opt out of e-mail communications at any time. Winking Bee Optometry does not share, distribute, or sell any patient information.

Occupation *

Employer *

How did you find Winking Bee? *

Vision Insurance

Subscriber *

Last 4 digits of subscriber SSID *

Relationship to Patient *

Home or Cell Phone *

Vision Insurance *

Do you have a secondary vision plan? *

Date of Birth *

Email *

Name of Health Insurance *

Is this an HMO or PPO? *

PPO HMO Not Sure

Emergency Contact

Name *

Phone Number *

Relationship to Patient *

Email *

Submit

Contact Information:
1100 Park Place, Suite 10
San Mateo, California 94403
Phone: (650) 212-2338
[email protected]
To access your patient records go to www.revolutionphr.com

Office Hours:
Sunday - Closed
Monday - Closed
Tuesday
Wednesday
Thursday
Friday
Saturday
*Closed Daily from 1 to 2
Closed May 24th for Memorial Day
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Closed
Closed
9:00am - 6:00pm
9:00am - 6:00pm
9:00am - 6:00pm
9:00am - 6:00pm
9:00 am -4:00pm

Optometrist in San Mateo | San Mateo Eye Care | San Mateo Eye Doctor

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