miyasakaeyecare.com - Patient Information Intake Form

PATIENT SIGN IN SHEET
Date

MonthDayYear
Date
Demographics
Name

First NameMiddle NameLast Name
Mr.Mrs.Ms.Dr.Prof
Preferred Name
Employment Status
Occupation
Preferred Language
MarriedSingleOther
MaleFemaleUnknown
Date of Birth

MonthDayYear
Date
SSN
Hispanic or LatinoNot Hispanic or LatinoDeclined to specify
American Indian or Alaska NativeAsianWhite or CaucasianNative Hawaiian or Pacific IslanderBlack or African AmericanDeclined to specify
Address & Phone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EmailTextPhone
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Referred by
YesNo
SelfOther
Same as aboveOther
Other Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician’s Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Other Doctor’s Name (if any)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax
Insurance information (Medical & Vision)

Please provide a copy of your insurance card(s) to the front desk at check‐in
Note: If you have Vision Service Plan (VSP) as your vision insurance, you will not have a physical insurance card.
Primary Medical Insurance
Insured ID
SelfSpouseChildOther
Subscriber’s Name
Subscriber’s DOB

MonthDayYear
Date
MaleFemaleUnknown
Subscriber’s last 4 of SSN
Secondary Medical Insurance
Insured ID
SelfSpouseChildOther
Subscriber’s Name
Subscriber’s DOB

MonthDayYear
Date
MaleFemaleUnknown
Subscriber’s last 4 of SSN
Primary Vision Insurance
Insured ID
SelfSpouseChildOther
Subscriber’s Name
Subscriber’s DOB

MonthDayYear
Date
MaleFemaleUnknown
Subscriber’s last 4 of SSN
Secondary Vision Insurance
Insured ID
SelfSpouseChildOther
Subscriber’s Name
Subscriber’s DOB

MonthDayYear
Date
MaleFemaleUnknown
Subscriber’s last 4 of SSN
I hereby authorize the providers at Richard H. Miyasaka, O.D., LLC or their representative(s) to release all medical information regarding my illness, care and/or injury to my insurance carriers, any health care facility, and any other physician that would benefit my health care. I assign my insurance benefits including Medicare, HMSA, and/or any other medical and/or vision insurance plan payable to Richard H. Miyasaka, O.D., LLC. The assignment will remain in effect unless revoked by me in writing.
I understand that I am financially responsible for all charges whether or not paid by my insurance.
Patient or Legal Guardian Signature

Clear
Date

MonthDayYear
Date
Print Name
SelfOther
Should be Empty:

PATIENT SIGN IN SHEET

Demographics

Address & Phone

Insurance information (Medical & Vision)