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Vision Source of Greenfield
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2017-07-06T01:14:22+00:00
Vision Source of Greenfield
Name
First
Middle
Last
How do you prefer to be addressed?
Mr.
Ms.
Dr.
Rev.
Mrs.
Marital Status
Single
Married
Divorced
Widowed
Sex
Male
Female
Date of Birth
MM slash DD slash YYYY
Social Security #
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Louisiana
Maine
Maryland
Massachusetts
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New Hampshire
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Full Time
Part Time
Self employed
Retired
Student
Not employed
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
MM slash DD slash YYYY
Parent/Guardian Signature (if applicable)
Date
MM slash DD slash YYYY
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