Sparks Eye Care General Patient Information

Name*
Prefix First Middle Last
How do you wish to be addressed?
Date of Birth
MM slash DD slash YYYY
Gender?
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Marital Status
Home Phone
Cell Phone
Work Phone
Email
Last 4 of SSN:

Used for purposes of patient access to secure patient portal
Emergency Contact
First Last
Emergency Contact Phone
Emergency Contact's Relationship to Patient
Emergency Contact Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I prefer to receive my appointment reminders by:
- Cell Phone Call
- Text (message charges may apply based on your plan)
- E-mail
Please check all that apply

Billing Information

Medication	Dosage

Medication/Substance	Reaction Type