Yin Eyecare

Patient's Name

First Middle Last Suffix

Name patient would like to be addressed by in the office

Patient's Date of Birth

Parents names, if patient is a child

Home Address

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

Home Telephone

Work Telephone

Cell Phone

Email Address

I prefer to be contacted by:

Home Phone
Cell Phone
Work Phone
Email

Is it OK if we text you regarding appointments?

Yes
No

Emergency Contact Name

First Last

Emergency Contact Phone

How did you find out about our office?

If referral, by whom?

Vision Insurance: Do you have VSP?

Yes
No

If 'No' please present your VISION insurance card to the receptionist.

If you have HEALTH insurance, please present your HEALTH insurance card. If you do not have vision or health insurance, you may skip the insurance questions below.

Do you have secondary vision or health insurance?

Yes
No

If 'Yes' please present this insurance card also

Are you a college student?

No
Yes, full-time
Yes, part-time

Is your insurance through YOUR employer?

Yes
No

What is the patient’s relationship to the insured member?

Spouse
Child
Grandchild
Other

What is the insured member’s full name?

First Last

What is the insured member’s date of birth?

Member’s employment status is:

Insured member’s employer

Unless we are a participating provider for your insurance plan, full payment for services is due at the time of the exam. Verifying eligibility does not guarantee payment from your insurance company. Payment in full is required for all materials (glasses and contact lenses) before they are ordered.

I understand that I am responsible for paying my co-payment and any non-covered services, such as contact lens evaluations and fittings, and material fees today. If for any reason my insurance company denies payment, the total fee for services and materials is my responsibility. I understand that returned checks will be charged an administrative fee.*

Signature

Date*