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Yin Eyecare
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2017-07-06T01:14:26+00:00
Yin Eyecare
Please complete the following information so that we may provide you better serice.
Patient's Name
First
Middle
Last
Suffix
Name patient would like to be addressed by in the office
Patient's Date of Birth
MM slash DD slash YYYY
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?
MM slash DD slash YYYY
Member’s employment status is:
Employed Full-Time
Employed Part-Time
Retired
Self-Employed
Active Military Duty
Other
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
*
MM slash DD slash YYYY
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