Eye Care Vision Center of Wauwatosa

Patient Information

Name*

First Last

Birth Date*

Prefix

Mr.
Mrs.
Ms.

Gender

Male
Female

Social Security #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Preferred Number

Home
Cell
Work

Email Address

Parent/Guardian Name (if under age 18)

First Last

Patient's Race

Ethnicity

Preferred Language

Employment (retired, employed full-time, employed part-time, student, etc.)

Employer/School

Computer User/Hobbies/Occupation

Insurance Company Name

Insured's Name

SS#

Birth Date

Untitled

Gender

Male
Female

Vision and Medical Information

Have you ever worn glasses?

Yes
No

Do you wear glasses now?

Yes
No

Do you currently wear contacts?

Yes
No

Do you want to be dilated?

Yes
No

Are you interested in contact lenses today? (If yes, a fitting/assessment fee will be charged)

Yes
No

Date of last general health exam

Doctor

Check any of the following health problems you ever had:

Family History (includes parents, grandparents, brothers, sisters)

Diabetes
Blindness
Glaucoma
Macular Degeneration
Heart Disease
Eye Disease
Hypertension
Crossed Eyes/Lazy Eye

What medications are you currently taking?

Are you allergic to any medications?

Who may we thank for referring you to our office?

Signature

I understand that, although I may have insurance, I am responsible for non-covered services, co-payments, or any claims submitted to my insurance company that are not paid by my insurance company for any reason. I also understand that if my account becomes delinquent and must be placed with a collection agency, I will be charged any fees incurred in addition to the unpaid balance.

Signature of Patient, Parent or Guardian*

Date*