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Testing Cover#1- JG [6068]
Jonathan Garcia
2023-05-04T18:13:16+00:00
[6068] Training Cover#1- JG
New Patient Registration form
First Name:
First Name:
MI:
MI:
Last Name:
Last Name:
How do you prefer to be addressed?
(nickname, Mr./Mrs., Dr., etc)
Marital Status:
Single /Married /Divorced /Widowed
Sex:
Male /Female
Date of Birth:
Social Security #
Mailing Address
Street Address
City:
City:
State:
State:
Zipcode:
Zipcode:
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone
Cell Phone
Email:
Note: We do not share your email address or phone numbers
Is Texting Ok?
YES
NO
Note: We do not share your email address or phone numbers
Is Emailing Ok?
YES
NO
Note: We do not share your email address or phone numbers
Employment Status
(Required)
Full Time/ Part Time
Self Employed
Retired
Student
Not Employed
Emergency Contact Name:
Emergency Contact Phone #:
Primary Care Physician:
Ins Policy holder:
Medical Ins:
Policy #:
Vision Ins:
Policy #:
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.
(Required)
I Understand
I Do Not Understand
******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.
Signature
(Required)
Date
(Required)
Date
Parent/Guardian Signature (if applicable)
___________________________________________
Parent/Guardian Date (if applicable)
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