[6068] Training Cover#1- JG

New Patient Registration form

First Name:
MI:
Last Name:
(nickname, Mr./Mrs., Dr., etc)
Single /Married /Divorced /Widowed
Male /Female
Street Address
City:
State:
Zipcode:
Home Phone
Work Phone
Cell Phone
Note: We do not share your email address or phone numbers
Is Texting Ok?
Note: We do not share your email address or phone numbers
Is Emailing Ok?
Note: We do not share your email address or phone numbers
Employment Status(Required)
Do you currently wear contact lenses?
*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 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.

Date
Parent/Guardian Date (if applicable)