Vision Boutique Wells

Gender

Male
Female

Title

Name*

First Middle Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Email Address

Primary Phone

Secondary Phone

SSN

Date of Birth*

Occupation / Employer

Emergency Contact / Phone Number

What is the main reason for today's exam?

When was your last eye exam?

How were you referred to our office?

Intenet Search
Phone book
School advertisement
Insurance Listing
Drive By
One of our patients

Who referred you?

Vision and Medical Insurance Information

Vision Boutique requires that all fees for professional services and materials be paid at the time the services and/or materials are rendered/ordered. I (the undersigned) agree that I am ultimately responsible for any portion of the final balance of my claim that is not covered by insurance.

Name of Vision Insurance

Subscriber same as patient?

No
Yes

Member Name

Member Date of Birth

Member SS#

Member ID#

Name of Medical Insurance

Subscriber same as patient?

No
Yes

Member Name

Member Date of Birth

Member SS#

Member ID#

Medical Information

How is your general health?

Do you take medications for any of these systems?

Please explain:

Do you have Diabetes?

No
Yes - Type 1
Yes - Type 2

Date of Diagnosis

Describe any medication allergies you may have:

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION - Please read carefully

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information (PHI) to carry out treatment, payment activities and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and other important matters about your protected health information. A copy of our Notice is on file for your review. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information (PHI) that we maintain. Complaints: You may complain to us or the Secretary of Health and Human Services if you believe we have violated your privacy rights. You may contact us at 312-829-6800 for further information about the complaints department. I have had the full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information (PHI) to carry out treatment, payment activities, and health care operations.

Signature

Date