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Please Print *All Areas with an asterisk must be completed.
*Name: _________________________________ *Age: _______Today’s Date: ______-______-______
*Address: _______________________________
*City/State/Zip: ___________________________ *Date Of Birth: _______-_______-_______
_______________________________________ *E-mail:______________________________
*Social Sec. #: _________-_________-_________ *Phone/Cell: (_______) _______- _______
Occupation: ________________________________ Employer: ____________________________
Guardian (if applicable): _________________________ Work/Alt. #: (_______) _______-_______
Name of Medical Doctor: ________________________ Last Medical Exam:______________________
*Name of Medical Insurance: _____________________ *Name of Vision Ins:_____________________
Policy Holder: _______________________________ Policy Holder:__________________________
ID Number: _________________________________ ID Number: ___________________________
Group Number: ______________________________ Grp/Plan Number: ______________________
DOB of Policy Holder: ________-________-________ DOB of Policy Holder: ______-_______-______
Medical History
Do you have any allergies? ○ No ○Yes If yes, Explain: ______________________________________________________________________________________________________________________________________________________________
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List any of the following you have had: Crossed Eyes, Lazy Eye, Drooping Eyelid, Double Vision, Retinal Disease, Cataracts, Dryness, Flashes/Floaters, Excess Tearing, Glaucoma, Eye Infections or Eye Injuries: ______________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________
Are you pregnant and/or nursing? ○No ○Yes
Do you wear glasses? ○No ○Yes If yes, how old is your present pair of glasses? _______
Do you wear contact lenses? ○No ○Yes If yes, how old is your present pair of lenses? ________
Type of contact lenses: ○Rigid ○Soft ○Other Are they Comfortable? ○Yes ○No
Do you currently, or have you ever had any problems in the following areas:
○Headaches ○Vascular Disease ○Cholesterol ○High Blood Pressure
○Migraines ○Thyroid/Other glands ○Diabetes
I certify that I have answered the above questions to the best of my knowledge. I authorize and request my insurance company to pay directly to the eye doctor insurance benefits for services rendered. I understand that my eye care insurance carrier may pay less than the actual bill for services. I aggress to be responsible for payment of all services rendered on my behalf or those of my dependents. I understand that all fees are due at the time of service and are non-refundable. I have read and understand the HIPAA privacy policy for this office as posed. J
X______________________________________________ ______________
SIGNATURE OF PATIENT (or parent if patient is a minor) DATE