Trainingcover2VF

Training Cover 2 VF

Name:(Required)

First Name MI Last Name

How would you like to be addressed?:

Marital Status:

Sex?:(Required)

Date Of Birth:(Required)

Social Security Number:(Required)

Mailing Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email:(Required)

Emailing is okay?(Required)

Yes

Texting is okay?

Yes

Employment Status:(Required)

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

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)

Date

Signature

Date