Overlake Family Vision

Patient Registration

Date*

Name*

First Last

Social Security Number*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Business Phone

Cell

Sex

Male
Female

Birthdate*

Age

Marital Status

Patient Employed By

Occupation

Business Address

Street Address Address Line 2 City State ZIP Code

Whom may we thank for referring you?

First Last

In case of an emergency, who should be notified?*

First Last

Emergency Contact Phone Number*

Email

Notice of Privacy Practices

We keep a record of the health care services that we provide for our patients. You may ask to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information. By my signature below, I acknowledge receipt of the Notice of Privacy:

Signature of patient or authorized representative*

Date*

Name if signed on behalf of the patient

First Last

Relationship to patient

Assignment and Release

I, the undersigned, certify that I (or my dependent) have insurance coverage (list below) and assign directly to Overlake Family Vision, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.

Insurance*

Responsible Party Signature*

Relationship

Date*

Medical History

Date of Last Eye Exam*

Clinic

Primary Care Physician

Please check any condition(s) that apply to your health:

Other Health Conditions or Surgeries

Please check any conditions which apply to your eye health:

Other Eye Health Conditions:

Please list any current medicines, eye drops, injections, or health devices you currently use. This includes non prescription items as well as prescription items. (for example, Tylenol and oral contraceptives.) Please indicate what each is taken for.

Are you allergic to any medications?*

What is your primary reason for your examination today?*

How many hours per day do you spend on a computer?*

Are you interested in contact lens vision correction?*

Are you interested in refractive surgery vision correction?*