Skip to content
Search for:
Training Patient Registration Form [Michael Grindler]
admin
2019-08-02T19:28:13+00:00
Training Patient Registration Form [Michael Grindler]
Name
*
First
Middle
Last
How do you prefer to be addressed?
(Nickname, Mr/Mrs., Dr., etc)
Marital Status
*
Single
Married
Divorced
Widowed
Sex
*
Male
Female
Date of Birth
*
Month
Day
Year
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
*
Full-Time
Part-Time
Self-employed
Retired
Student
Not Employed
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
*
MM slash DD slash YYYY
Parent/Guardian Signature (If Applicable)
Date
MM slash DD slash YYYY
Patient File Number
Go to Top