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Patient Name


First Name:     Middle Name:
Last Name:     Sex:  

Physical Address


Street 1:     Street 2: 
City:     State: 
Zip: 

Billing Address Same as Physical Address: 

Billing Address


Street 1:     Street 2: 
City:     State: 
Zip: 



Contact Information


Home Number:     Work Number: 
Cell Number: 

Email: 

Preferred Contact: 


Work Information


Employer:     Occupation: 

Social Security Number:     Date of Birth

Doctor Information


Patient's Medical Doctor:     City: 

Parent / Spouse Information


Responsible Party: 
Parent / Spouse Name:     Parent / Spouse DOB

Parent / Spouse SSN:     Parent / Spouse Employer: 



Vision Insurance Information


Have Vision Insurance: 
Vision Insurance:     Subscriber's Name: 

Subscriber's ID:     Subscribers Birth Date


Medical Insurance Information


Have Medical Insurance: 
Primary Medical Insurance:     Secondary Medical Insurance: 
Subscriber's Name: 

Subscriber's ID:     Subscribers Birth Date


We are a participating member of Medicare and our office accepts most vision and medical insurance plans. If you are insured by a plan that we do not participate in, please let us know and we will do our best to offer you the same benefits.

I authorize this office to release any information needed to process any insurance claim. I understand that I am responsible for any charges regardless of insurance coverage.




Pharmacy Information


Pharmacy Name:     Pharmacy Location: 
Pharmacy Number: 

Name of Responsible Party:     Date

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By signing this, you are agreeing to the HIPAA Notice of Privacy Policies document at the link above.





 

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