Name

First Middle Last

Preferred name

Gender

Male
Female

Date of Birth

Social Security Number (last 4 digits only!)

Email

Address

Street Address Address Line 2 City State Zip Code

Primary Phone

Secondary Phone

Emergency Contact Name

Emergency Contact Phone

Children in Family

Name	Age

Referred By

Family Member

Yes
No

Online

Yes
No

Insurance Provider

Yes
No

Other

Yes
No

Complete this section If patient is under 18 years of age

Parent / Legal Guardian Name

Parent / Guardian Social Sec. #

If student, grade 1-6, write school, grade and teacher's name

Please list any additional persons you authorize to access your personal health information (PHI), including billing and medical records information

Full Name	Relationship

Race

American Indian Or Alaska Native
Native Hawaiian
Asian
White
Black Or African American
Declined To Specify
Hispanic Or Latino
Other Race

Ethnicity

Hispanic Or Latino
Not Hispanic Or Latino
Declined To Specify

Language

English
Spanish
French
Arabic

Height

Ft	In	Cm/M

Weight

Occupation

Employer

Physician Details

Primary care physician

Last Exam Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Eye Care Physician's Name

Last Exam Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insurance Plan

Name of Insurance

Insured Patient's Name

Insured Pt's ID Number

Group Plan Name / Number ID

Relation to Policyholder

Self
Spouse
Child
Other

Secondary Insurance Plan

Name of Insurance

Insured Patient's Name

Insured Pt's ID Number

Group Plan Name / Number ID

Relation to Policyholder

Self
Spouse
Child
Other

Patient History Form

Referred By

Complete this section If patient is under 18 years of age

Physician Details

Primary Insurance Plan

Secondary Insurance Plan

Five Points Eye Care