[5978] Training Cover #2 – RG – Patient Registration Forms

Name

First Name MI Last Name

How do you prefer to be addressed? (Nickname, Mr./Mrs., Dr., etc)

Marital Status

Sex

Male

Female

Date of Birth

Social Security #

Mailing Address

Apt

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Texting is ok?

Yes

Note: We do not share your email address or phone numbers

Email is ok?

Yes

Employment Status

Primary Care Physician

Medical Ins.

Policy #

Ins. Policy Holder

Vision Ins.

Policy #

Emergency Contact Name

Phone Number

Hobbies

Main reason for today's visit:

Do you currently wear contact lenses?

Yes

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

Parent/Guardian Signature (if applicable)

Date

Patient File Number

[5978] Training Cover #2 - RG