Patient Information

Patient Name *

Prefix

First

Last

Suffix

Sex *

Home Address *

Street Address

Address Line 2

City

State

Zip

Home Phone *

Work Phone *

Date of Birth *

Day

Month

Year

Age *

Emergency Contact *

When was your last eye exam? *

Where was your last eye exam? *

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 *

Day

Month

Year

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