4906 LC Eye Clinic

Name*

First MI Last

How do you prefer to be addressed?

(nickname, Mr./Mrs., Dr., etc)

Marital Status

Single
Married
Divorced
Widowed

Gender*

Male
Female
Prefer Not to Answer

Date of Birth*

Social Security Number*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number(s)*

Cell	Home	Work

(###)###-####

Texting is ok*

Yes
No

Email*

Emailing is ok*

Yes
No

Employment Status

Primary Care Physician Medical Ins Policy #

Ins Policy Holder Vision Ins Policy #

Emergency Contact Name*

First Last Phone Number

Hobbies

Main Reason for Today's Visit

Do you currently wear contact lenses?*

Yes
No

What type of lens do you wear?

Any problems with your current glasses or contacts?*

Yes
No

If so, please briefly describe

Consent*

There are fees to evaluate and update a contact lens prescription. I understand that these fees are not covered
by most insurance, vision, or managed care plans as it is not considered part of a routine eye exam. I will notify
the staff if I decide not to have this service performed.
I understand and agree that health insurance policies are an arrangement between an insurance carrier and
myself. I authorize payment from my insurance carrier direct to this office with the understanding that all
monies will be credited to my account of receipt. However, I clearly understand and agree that all services
rendered are charged directly to me and that I am personally responsible for payment. I also authorize release
of any medical information that may be required in determination of benefits. I have received a copy of Vision
Source's Privacy Statement.

I agree to the privacy policy.

Patient's Signature

Parent/Guardian Signature

(If Applicable)

Date*

MM

DD

YYYY

Patient File Number