Training Cover #1 – KF – Patient Registration Forms

Training Cover #1 - KF

Training Patient Registration Form

Name(Required)

First Middle Last

How do you prefer to be addressed? (nickname, Mr./Mrs., Dr., etc)(Required)

Marital Status:(Required)

Sex:(Required)

Date of Birth:(Required)

Social Security #(Required)

Mailing Address:(Required)

Apt:

City:(Required)

State:(Required)

Zipcode:(Required)

Home Phone:

Work Phone:

Cell Phone:(Required)

Texting is ok:(Required)

Email:(Required)

Note: We do not share your email address or phone numbers

Emailing is ok:(Required)

Employment Status:(Required)

Primary Care Physician:

Medical Ins:

Policy #:

Ins Policy holder:

Vision Ins:

Policy #:

Emergency Contact Name:

Emergency Contact Phone:

Hobbies:

Main reason for today's visit:(Required)

Do you currently wear contact lenses?(Required)

Yes

If yes, what type of lens do you wear?

Any problems with your current glasses or contacts?

Label(Required)

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.

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.(Required)

Patient's Signature(Required)

Date(Required)

Parent/Guardian Signature (if applicable)

Date

Patient File Number: