Vision Source of Greenfield

Name

First Middle Last

How do you prefer to be addressed?

Marital Status

Sex

Male
Female

Date of Birth

Social Security #

Mailing Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Texting is ok

Yes
No

Email

Emailing is ok

Yes
No

We do not share your email address or phone numbers

Employment Status

Primary Care Physician

Medical Insurance

Policy Number

Insurance Policy Holder

Vision Insurance

Policy Number

Emergency Contact Name

Phone

Hobbies

Main Reason for Visit

Do you currently wear contact lenses?

Yes
No

What type of lens do you wear?

Any problems with your current glasses or contacts?

Yes
No

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's Signature

Date

Parent/Guardian Signature (if applicable)

Date