Welcome Back Form

Welcome Back Form
Welcome Back!Thank you for taking the time to fill out this form to make sure our records are up to date!
Mr. Mrs. Ms. Other
Preferred Pronouns: He/Him She/Her They/Them
Name

First NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth: Date SSN(if applicable): Type a label
Email
example@example.com
EMERGENCY CONTACT
First Name Last Name Relationship: Type a label
Phone: Area Code Phone Number
MEDICATION CHANGES(if applicable)
Type a label
VISION INSURANCE (if applicable)
Insurance Company:      ID:#
Primary Insured:   First Name   Last Name   Date of birth:   Date
Relationship to Insured:
MEDICAL INSURANCE (if applicable)
Insurance Company:   *   ID:#
Primary Insured:   First Name   Last Name   Date of birth:   Date
Relationship to Insured:
I have provided any and all insurance information. If any is withheld at time of service, I acknowledge I am responsible for the usual and customary charges for services rendered.
Signature*

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Date

MonthDayYear
Date
I have read and agree to the Office Policies agreement set by Griswold Eye Care, PLLC.
Signature*

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Date

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Date
HIPAA POLICY: Please read carefully. Signature Required.I agree to allow my medical information be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am aware that Griswold Eye Care has a notice of privacy practicesavailable to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records.
Signature*

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Date

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Date
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Welcome Back Form

Welcome Back!Thank you for taking the time to fill out this form to make sure our records are up to date!