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Ralph Training Eyecare
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2021-04-21T13:00:02+00:00
Ralph Training Eyecare
First Name:
MI:
Last Name:
How do you like to be addressed? (nickname, Mr./Mrs., Dr, etc)
Marital Status:
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Sex:
Male
Female
Date of Birth:
MM slash DD slash YYYY
Social Security #
Mailing Address:
Street Address
Address Line 2
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Texting is okay:
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Note: We do not share your email address or phone numbers
Emailing is okay:
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No
Employment Status
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Primary Care Physician:
Medical Ins:
Policy #
Ins Policy Holder:
Vison Ins:
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?
Consent
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.
Consent
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
Patient's Signature
Date
MM slash DD slash YYYY
Patient File Number:
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