Name

Date of Birth

Sex

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Home Phone

Cell Phone

Email

Emergency Contact

Your last eye exam

Where

How did you hear about us?

Do you use

Glasses
Contacts

Do you want new

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.

Signature

Date

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

Patient History Form

Patient History Form

Insurance Information

Dr.’s Eyecare Center