Patient Registration

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*

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*

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:*

Lee Sitel Test 1

Patient Registration Form