FORM 10: Existing Patient INFO UPDATE

Dr. Bream & Associates

Form 10: Existing patient INFO UPDATE
If you are an existing patient of our clinic, and if you require any information update such as email, address, last name, health card version code, phone number, insurance provider information etc., please fill this form 24 hours PRIOR to your appointment with our physicians.

Thank you
EYETELLIGENCE Team

PATIENT PROFILE
Today's Date

MonthDayYear
Optometrist
Your appointment Date & Time:

MonthDayYear
Hour MinutesAM/PM Option
Name (exactly as shown in your health card)

First NameLast Name
OHIP Number (MUST be valid)
OHIP Version Code
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell Phone (For the purpose of appointment reminder TEXT messages)
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email (reminders, forms, invoice, prescription, educational material will be sent to your email)
Preferred Contact
2nd Preferred Contact
Occupation (or Grade)
Employer (or School)
Spouse's (or Parent's) Name
Do you drive?
Does the staff who booked the appointment, clearly communicated the professional fee for your appointment along with any additional "non-OHIP" service fees in the event it is required by the physician?
Your Appointment Type:
Do you have any insurance contribution through your employer/private or through a family member?
Provider
INSURANCE CONTRIBUTION: If you, parents or spouse have any private insurance contribution, please provide. We only need this information in the event you would like us to help you with direct claim. We strongly suggest you call your insurance provider to find your *eligibility* *coverage* *any health expense amount* and if your plan *permits direct payment to your healthcare provider* prior to the appointment. Insurance providers are only available to answer between M-F 8am-4pm. PLEASE ENTER "NONE" IF YOU DO NOT HAVE ANY OF THE SPECIFIC INSURANCE COVERAGE.
OTHER
Family Doctor
Date of Last Physical

MonthDayYear
Name
Signature Date
Signature
Should be Empty:

Dr. Bream & Associates