Family Optometric Vision Care

Welcome to Family Optometric Vision Care!
NAME:
First Last
DATE:
Date Format: MM slash DD slash YYYY
GENDER:
DOB:
Date Format: MM slash DD slash YYYY
AGE:
SSN#:
ADDRESS:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
OCCUPATION:
How did you hear about us?
- Yelp
- Google
- Insurance
If someone referred you, please list their first and last name:
CONTACT INFORMATION:
Home Phone:
Cell Phone:
Work Phone:
Personal Email:
*If under the age of 18 parent or guardian information:
Phone#:
Name:
First Last
Relation:
VISION INSURANCE:
Name of Ins:
Policy Holder's Name:
First Last
Policy Holder's SSN:
Policy Holder's DOB:
Date Format: MM slash DD slash YYYY
Name of 2nd Ins:
Policy Holder's Name:
First Last
Policy Holder's SSN:
Policy Holder's DOB:
Date Format: MM slash DD slash YYYY
MEDICAL INSURANCE:
Name of Ins:
Policy Holder's Name:
First Last
Policy Holder's SSN:
Policy Holder's DOB:
Date Format: MM slash DD slash YYYY
Acknowledgement of Receipt of Notice of Privacy Practices
In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct healthcare operations involving our office. By signing this form below, you acknowledge having received the Notice of Privacy Practices from Family Optometric Vision Care.
Financial Responsibility Waiver
Insurance Authorization, Verification, and Co-Payments are the responsibility of the member. I understand that if my insurance benefits and/or eligibility are not approved by my health plan, then I am financially responsible and agree to pay for all charges related to services provided by Family Optometric Vision Care. This waiver will remain valid from this day forward to include all future services related to this patient.
Signature (or Guardian)
Date
Date Format: MM slash DD slash YYYY

Welcome to Family Optometric Vision Care!

Acknowledgement of Receipt of Notice of Privacy Practices

Financial Responsibility Waiver