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Maurice Sitel Test 1
Maurice Lapez
2021-03-12T13:34:44+00:00
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
Single
Married
Divorced
Widowed
Sex
Male
Female
Date of Birth
MM slash DD slash YYYY
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
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable)
Date
MM slash DD slash YYYY
Patient File Number
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