Training Cover 1- rt

Name*

First Last

Birthdate*

Social Security Number

Email*

Marital Status*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone*

Business Phone

Name of Parent or Spouse*

First Last

Have we examined other members of your family?*

Yes
No

Occupation

Employer

Insurance Company*

Member Name*

First Last

Member DOB*

Member Number*

Name of Family Physician*

First Last

How Did You Find Out About Our Office*

What Is Your General Health Status?*

List All Medications You Are Taking*

Pharmacy Name*

Pharmacy Phone Number*

Medication Allergies*

List All Major Illnesses, Injuries, Surgeries In The Last 10 Years*

Are You Pregnant?*

Yes
No

Name of Last Eye Doctor*

First Last

Date Of Last Eye Exam*

Do You Wear Eyeglasses?*

Yes
No

Do You Wear Contact Lenses*

Yes
No

Current Eyedrops

List All Current or Past Eye Diseases, Eye Injuries, or Eye Surgeries*

Family History (Family History includes your parents, grandparents, siblings, and your children)*

Do You Use Tobacco Products?*

Current
Previous
Never

Do You Drink Alcohol?*

Socially
Daily
Never

Patient Eye Health*

Patient General Health

Consent*

I agree

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.

Signature