Maurice Sitel Test 1

New Patient Information Form

Name*

First Name MI Last Name

How do you prefer to be addressed? (Nickname, Mr./Mrs., Dr., etc)

Marital Status

Sex

Date of Birth

Social Security Number

Address

Mailing Address Apartment City State Zipcode

Home Phone

Work Phone

Cell Phone

Texting is ok:

Yes
No

Email

Emailing is ok:

Yes
No

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

Employment Status

Full Time
Part Time
Self Employed
Retired
Student
Not Employed

Primary Care Physician

Medical Insurance

Policy Number

Insurance Policy Holder

Vision Insurance

Policy Number

Emergency Contact Name

First Last

Phone

Hobbies

Main reason for today's visit

Do you currently wear contact lenses?

Yes
No

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.

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.

Patient's Signature

Date

Parent/Guardian Signature (if applicable)

Date

Patient File Number