Patient Information Form

Today's Date

Date

Patient's Name

Last NameFirst Name

Date of Birth

Date

Sex

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone

Please enter a valid phone number.Format: (000) 000-0000.

Home Phone

Please enter a valid phone number.Format: (000) 000-0000.

Preferred: Cell or Home

Email Address

example@example.com

Employer/School

Occupation

What is the main purpose of this visit?

Do you have any problems with your current vision correction? If yes, please describe.

Do you work at a Desktop? Laptop? Tablet? Phone?

How many hours per day?

Do you spend time outdoors?

How many hours per week?

Do you play any sports?

If yes, please list:

Do you consume alcohol?

If yes, how often?

Do you use any tobacco products?

If yes, how often?

Do you work at a Desktop? Laptop? Tablet? Phone? YES or NO How many hours per day?

Do you spend time outdoors? YES or NO How many hours per week?

Do you play any sports?

Do you consume alcohol? YES or NO How often?

Do you use any tobacco products? YES or NO How often?

Vision Insurance

ID#

Subscriber Name

Subscriber Birth Date

Date

Subscriber Last 4 Digits of SS#

Primary Medical Insurance

Subscriber Name

Subscriber Birth Date

Date

HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I hereby acknowledge I understand Linsey Eyecare's Notice of Privacy Practices. Furthermore, I acknowledge that a copy of the current notice is posted in the reception area. If you would like to receive a printed copy, please request it at the reception desk during check-in.

Signature

Date

Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company, not Linsey Eyecare. If your insurance company does not reimburse our office, you are responsible for providing payment to Linsey Eyecare upon receipt of invoice.

Signature

Date