Tell Us About Yourself - Eye Care Intake Form

Patient Information
Patient Gender
Patient Name

First NameLast Name
Patient Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Name and Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient or Caregiver's E-Mail
example@example.com
Reason for seeing the doctor:
Insurance Information
If Other (HMO/PPO or Medicare Supplement Name)
Insurance Number
If Vision Plan
Vision Care Insurance Number
Patient's Primary Care Physician (Doctor)
Patient Medical History
Have you ever had or experienced (Please check all that apply)
Other illnesses:
Eye Care Appointment Preference
Will you need transportation to your Eye Care appointment?
Are you or the client a referral from the Detroit Area Agency on Aging - Vision Access Detroit Program?
Appointment - Please schedule a preferred date of appointment at least 24-48 hours from today's date. The date and time that you select is not guaranteed. Intake will call to confirm the "actual visit/appointment day and time" once your insurance/form of payment is verified. - Fridays are reserved for mobile/in-home eye appointments.
Signature
Should be Empty:

Patient Information