Ralph Training Eyecare

First Name:
MI:
Last Name:
How do you like 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 #
Mailing Address:
Street Address Address Line 2 City State ZIP Code
Home Phone:
Work Phone:
Cell Phone:
Texting is okay:
- Yes
- No
Email:

Note: We do not share your email address or phone numbers
Emailing is okay:
- Yes
- No
Employment Status
- Full Time
- Part Time
- Self Employed
- Retired
- Student
- Not Employed
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: