Looking Glass Eye Center Patient Information Form

Patient Name

First Last

Date of Birth

Social Security #

Mailing Address

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

Main #

Alternate #

Employer

Work #

Email

Preferred Method of Contact

Main #
Alterrnate #
Mail
Email

Marital Status

Single
Married
Widowed
Other

Primary Language

English
Spanish
Other

Race

White
Black/African American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific
Decline to Answer

Primary Care Physician

Emergency Contact

First Last

Phone #

Relationship to Patient

PERSON RESPONSIBLE FOR ACCOUNT (PARENT/GUARDIAN)

Name

First Last

Date of Birth

Address (if different from above)

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

Phone #

Social Security #

Relationship to Patient

PLEASE PRESENT YOUR INSURANCE CARDS TO BE SCANNED AT TIME OF SERVICE

I authorize Looking Glass Eye Center to release any information to any insurance company that may be needed to process an insurance claim for myself or my dependent. I assign any payable benefits to Looking Glass Eye Center. with or without insurance, I understand that I am responsible for all charges incurred while under the care of Looking Glass Eye Center.

Signature

Date