Eye Health Solutions

Name*

First Middle Last

Preferred Name*

Street Address*

Street Address City State / Province / Region ZIP / Postal Code

Mailing Address same as Street Address?*

Yes
No

Mailing Address

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

Date of Birth*

Email

Home Phone*

Cell Phone

May we send you text messages?*

Yes
No

May we leave voice mails?*

Yes
No

With whom may we leave messages at your home regarding appointments and billing?*

What is your preferred method of communication?*

Cell Phone
Home Phone
Email

Marital Status*

Name of spouse

Employment Status*

Full Time
Part Time
Not employed

Occupation*

Employer*

Work Phone

May we call your work phone?*

Yes
No

Are you a full time student?*

Yes
No

School

Do you have any of the following:*

Diabetes
Glaucoma
Macular Degeneration
None

Health Insurance Subscriber (the individual who carries the insurance)*

Patient
Other

Subscriber ID*

Subscriber Name*

First Last

Relationship to Patient*

Date of Birth*

Phone*

Subscriber Address Same as Patient?*

Yes
No

Address*

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

Emergency Contact*

First Last

Relationship to Patient*

Emergency Contact Phone*

If you are a new patient, how did you find us?*

Please tell us specifically who referred you.*

Signature of Patient or Parent/Guardian

I am responsible for payment at the time of each visit for all services provided by Dr. Scott Smith or Eye Health Solutions which are not covered by insurance. I authorize assignment of all medical benefits to Dr. Scott Smith or Eye Health Solutions, and I authorize the release of any medical information needed to process insurance claims. This acknowledgement and authorization applies to all services until revoked by me in writing.

Signature*

Date*