Patient Information

Patient Name *

Prefix

First

Last

Suffix

Sex

Address *

Street Address

Address Line 2

City

State

Zip

Home Phone

Work Phone

Date of Birth

Month

Day

Year

Age

Emergency Contact

Your last eye exam

Where

How did you hear about us?

Do you use

Glasses

Contacts

Do you have a specific problem or need?

Eye history include any disease, injuries, surgery

Specify any medical conditions you have?

Current medications

Family Physician

Phone

Insurance Information

Medical insurance

Subscriber name

Date of birth

List 4 SS#

ID

Relation to Subscriber

Vision insurance

I authorized and consent to the examination and treatment of the above patient. I certify that the information above is correct. I authorize the doctor to release any information needed to process my insurance claims and I assign payment to the provider of any benefits. I am responsible for any copays at the time of the visit and I will forward payment for any expenses applied to my deductible once my insurance company is billed. Full payment is due for out of pocket contact / glasses expenses before they can be ordered. *

I agree

Date

Month

Day

Year

* Patient records only maintained for six years after the visit.