Skip to content
Search for:
Patient Registration
Lee Caradang
2021-03-12T20:17:12+00:00
Lee Sitel Test 1
test 2
Patient Registration Form
Name
*
First
Middle
Last
How do prefered to be addressed? (nickname, Mr./Ms., Dr., etc)
*
Marital Status
*
Single
Married
Divorced
Widowed
Date of Birth
*
MM slash DD slash YYYY
Social Security #:
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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
*
Part time
Self Eployed
Retired
Student
Not Employed
Primary Care Physicians:
*
Medical Insurance
*
Policy #:
*
Insurance Policy Holder:
*
Vision Insurance:
*
Policy #:
*
Emergency Contact Name:
*
Phone #:
*
Hobbies:
*
Main reason for today's visit:
*
Do you currently wear contact lenses?
*
Yes
No
If yes, 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 and Date:
*
Parent/Guardian Signature (if applicable) Date :
Patient File Number:
*
Go to Top