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 Training Cover #1 – RG
 Training Cover #1 - RG
How do you prefer to be addressed? (Nickname, Mr./Mrs., Dr., etc)
Date of Birth
Social Security #
Texting is ok?
Note: We do not share your email address or phone numbers
Email is ok?
Primary Care Physician
Ins. Policy Holder
Emergency Contact Name
Main reason for today's visit:
Do you currently wear contact lenses?
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.
Parent/Guardian Signature (if applicable)
Patient File Number
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