[6073] Training Cover#2- JG

New Patient Registration form

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 of Birth:

Social Security #

Mailing Address

Street Address

City:

State:

Zipcode:

Home Phone

Work Phone

Cell Phone

Email:

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

Is Texting Ok?

YES

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

Is Emailing Ok?

YES

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

Employment Status(Required)

Full Time/ Part Time

Self Employed

Retired

Student

Not Employed

Emergency Contact Name:

Emergency Contact Phone #:

Primary Care Physician:

Ins Policy holder:

Medical Ins:

Policy #:

Vision Ins:

Policy #:

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.(Required)

I Understand

I Do Not Understand

****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.

Signature(Required)

Date

Parent/Guardian Signature (if applicable)

___________________________________________

Parent/Guardian Date (if applicable)