Training Patient Registration Form [Michael Grindler]

Name*
First Middle Last
How do you prefer to be addressed?
(Nickname, Mr/Mrs., Dr., etc)
Marital Status*
Sex*
Date of Birth*
MM
DD
YYYY
Social Security #*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone
Cell Phone*
Texting is Ok*
- Yes
- No
Email*

Note: We do not share your email address or phone numbers
Emailing is Ok*
- Yes
- No
Employment Status*
Primary Care Physician*
Medical Insurance*
Policy #*
Insurance Policy Holder*
Vision Insurance*
Policy #*
Emergency Contact*
First Last
Emergency Contact Phone*
Hobbies
Main reason for today's visit*
Do you currently wear contact lens?*
- Yes
- No
If yes, what type of lens do you wear?
Any probems 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. 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.
Patient Signature*
Date*
Date Format: MM slash DD slash YYYY
Parent/Guardian Signature (If Applicable)
Date
Date Format: MM slash DD slash YYYY
Patient File Number