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[5731] Training Cover # 1
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2022-06-23T17:02:08+00:00
[5731] Training Cover # 1
First Name:
MI:
Last Name:
How do you prefer to be addressed? (nickname, Mr./Mrs., Dr., etc)
Marital Status:
Single
Married
Divorced
Widowed
SEX:
Male
Female
Date
MM slash DD slash YYYY
Social Security #:
Mailing Address:
Apt:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Texting OK?:
Yes
No
Email:
Emailing Okay?:
Yes
No
Employment Status
Full time
Part Time
Self Employed
Student
Retired
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 currently wear contact lenses?
Yes
No
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 the release of any medical information that may be required in the determination of benefits. I have received a copy of Vision Source's Privacy Statement.
I Accept
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 the release of any medical information that may be required in the determination of benefits. I have received a copy of Vision Source's Privacy Statement.
Patient's Signature:
Date
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable):
Date
MM slash DD slash YYYY
Patient File Number:
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