Established Patient Packet

Established Patient Information

Bring your photo ID

Name

Date of Birth

SSN

Has your address changed since last visit?

Yes No

Addess

City

Zip

Has your phone number changed since last visit?

Yes No

Phone Number

Home

Marital status:

Single Married Other

Please specify if other.

Occupation

Place of employment

Spouse or partners name

Date of Birth

SSN

Financially Responsible Party

Spouse

Parent/guardian

Male

Female

Name

BirthDate

SSN

Street Address

City

Zip

Insurance Bring your insurance card[s]

Only complete if insurance has changed since last visit.

Insurance #1 (Primary Insurance- This will be filed first)

Insurance company

Contract Number

Group number

Subscribers Last Name

First Name

Middle Name

Social security number

Date of Birth

Sex

Male Female

Relationship to patient

Insurance #2 (Secondary Insurance-This will be filed after primary insurance pays)

Insurance company

Contract Number

Group number

Subscribers Last Name

First Name

Middle Name

Social security number

Date of Birth

Sex

Male Female

Relationship to patient

Emergency Contact

Name

Relationship

Cell

Established Patient History

Established Patient History (Blank answers will be recorded as no/negative in your electronic record.)

Name

Date of Birth

What is your current eye problem?

List any discontinued or new medicines with dosage and frequency

Have you had any new medical problems or major surgery since your last visit?

My responses are accurate for use in my medical decision making.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Your information will be encrypted.