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Training Cover #1 – KF
Kainan Fiyalko
2023-05-02T13:18:52+00:00
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)
Single
Married
Divorced
Widowed
Sex:
(Required)
Male
Female
Date of Birth:
(Required)
Month
Day
Year
Social Security #
(Required)
Mailing Address:
(Required)
Apt:
City:
(Required)
State:
(Required)
Zipcode:
(Required)
Home Phone:
Work Phone:
Cell Phone:
(Required)
Texting is ok:
(Required)
Yes
No
Email:
(Required)
Note: We do not share your email address or phone numbers
Emailing is ok:
(Required)
Yes
No
Employment Status:
(Required)
Full Time
Part Time
Self Employed
Retired
Student
Not Employed
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
No
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)
Month
Day
Year
Parent/Guardian Signature (if applicable)
Date
Month
Day
Year
Patient File Number:
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