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Trainingcover2VF
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2022-01-11T16:42:20+00:00
Training Cover 2 VF
Name:
(Required)
First Name
MI
Last Name
How would you like to be addressed?:
Mr.
Mrs.
Other
Marital Status:
Single
Married
Divorced
Widowed
Sex?:
(Required)
Male
Female
Date Of Birth:
(Required)
Month
Day
Year
Social Security Number:
(Required)
Mailing Address:
(Required)
Street Address
Address Line 2
City
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Armed Forces Americas
Armed Forces Europe
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State
ZIP Code
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Email:
(Required)
Emailing is okay?
(Required)
Yes
No
Texting is okay?
Yes
No
Employment Status:
(Required)
Full Time
Part Time
Self Employed
Retired
Student
Unemployed
Primary Care Physician:
Medical Ins:
Policy #:
Ins Policy Holder:
Vision Ins:
Policy #:
Emergency Contact Name:
Phone Number:
Hobbies:
Main Reason for Today's visit:
(Required)
Do you currently wear contact lenses?:
Yes
No
If yes, what type of lens do you wear?:
Any problems 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.
(Required)
I agree
I do not agree
Patient Signature:
(Required)
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Signature
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