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Test Cover #2-CB 5440
Cassandra Berchin
2021-11-05T15:07:09+00:00
Test Cover #2-CB 5440
First Name
Middle Initial
Last Name
How do you prefer to be addressed?
Nickname, Mr./Mrs., Dr, etc.
Sex:
Male
Female
Marital Status
Married
Single
Divorced
Widowed
Date of Birth
MM slash DD slash YYYY
Social Security Number
Street Address
Apt
City
State
Zipcode
Home Phone
Work Phone
Cell Phone
Texting is ok?
Yes
No
Email Address
Emailing is ok?
Yes
No
Note: we do not share your email address or phone numbers
Employment Status
Full Time
Part Time
Self Employed
Retired
Student
Not Employed
Emergency Contact
Emergency Contact Phone Number
Primary Care Physician
Insurance Policy Holder
Medical Insurance
Policy Number
Vision Insurance
Policy Number
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?
Important Information
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 a 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.
I understand and agree
Patient's Signature
Date
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable)
Date
MM slash DD slash YYYY
Patient File Number:
Office Use only
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