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[5235] MGC Optical Solutions Form 1
Mary Castro
2021-06-25T17:35:55+00:00
[5235] MGC Optical Solutions Form 1
New Patient Information Form
Name
First
Middle
Last
How do you prefer to be addressed? (nickname, Mr./Mrs., Dr., etc)
Marital Status
Single
Married
Widowed
Divorced
Separated
Sex
Male
Female
Date of Birth
MM slash DD slash YYYY
Social Security #
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Work Phone
Cell Phone
Texting is okay
Yes
No
Email
Emailing is okay
Yes
No
We do not share your email address or phone numbers.
Employment Status
Full Time
Part Time
Self Employed
Retired
Student
Not Employed
Primary Care Physician
Medical Insurance
Policy #
Insurance Policy Holder
Vision Insurance
Policy #
Emergency Contact Name
Phone #
Hobbies
Main reason for today's visit
Do you currently wear contact lenses?
Yes
No
If yes, what type of lens do you wear?
Any problems with your current glasses or contacts?
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.
Patient's Signature Date
Date
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable)
Date
MM slash DD slash YYYY
Patient File Number
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