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5449 Smith Eyecare
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2021-11-10T22:03:53+00:00
5449 Smith Eyecare
Name
*
First Name:
MI:
Last Name:
How do you prefer to be addressed? (nickname, Mr.,/Ms., Dr., ect)
Marital Status:
*
Single
Married
Divorced
Widow/Widower
Sex:
*
Male
Female
Date of Birth:
*
MM slash DD slash YYYY
Social Security #
Mailing Address:
*
Street Address
Apt
City
State
Zipcode
Home Phone:
Work Phone:
Cell Phone:
*
Texting is ok:
*
Yes
No
Email
*
Emailing is ok:
*
Yes
No
Employment Status
Full time
Part time
Self emplyed
Retired
Student
Not employed
Primary Care Physician:
Medical Ins:
*
Policy #:
*
Ins Policy Holder:
*
Vision Ins:
*
Policy #:
*
Emergency Contact
*
Name:
Phone :
Hobbies
*
Main reason for today's visit:
*
Do You Wear glasses or contacts?
*
Yes
No
If yes, what type of lens do you wear?
Any problems with your current glasses or contacts?
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Patients Signature
Date
Parent/Guardian Signature (if applicable)
Date
Patient File Number:
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