Existing Patient Paperwork

Name

First NameMiddle InitialLast Name
Gender

MaleFemale
Social Security #
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code
Employment

Full TimePart TimeSelf EmployedRetiredNot EmployedStudentMilitary
Marital Status

MarriedSingleDivorcedWidowedLegally Separated
Race

American Indian or Alaska NativeAsianBlack or African AmericanEuropeanHispanicNative Hawaiian or Other Pacific IslanderWhite
Home Phone #
Cell Phone #
Communication Preference

TelephonePostalEmail
Email
RESPONSIBLE PARTY
Name

First NameLast Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Home Phone #
Cell Phone #
Social Security #
Date of Birth

MonthDayYear
Date
INSURANCE INFORMATION
Insurance Company
Policy Holder Name
Policy Holder DOB
Patient Relationship to Holder
Insurance ID #
Group #
POLICY FOR EYEWEAR AND CONTACT LENSES
All sales of prescription and non-prescription eyeglasses, sunglasses, and contact lenses are FINAL! If there is a need for the prescription to be adjusted, such changes are included at no charge for a one-time redo within 90 days of purchase. All eyeglasses and contact lenses that have been prescribed, fitted, and purchased by the patient will be kept in the office for a total of 6 months from the date of purchase. If the patient does not pick them up within that time frame, they will be donated to charity and no refund will be issued.
PERSONAL CHECKS AND BOUNCED CHECKS
Any bounced personal check is subject to a fee of $35, which is to be paid, in addition to the original amount, within 30 days. After the 30 day period has expired the check will be turned over to the county attorney for collection.
By signing below, you are agreeing to have read and understood all aspects of the above policies.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

RESPONSIBLE PARTY

INSURANCE INFORMATION

POLICY FOR EYEWEAR AND CONTACT LENSES

PERSONAL CHECKS AND BOUNCED CHECKS