Name*

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

Date of Birth*

Social Security Number*

(last 4 digits only)

Age*

Occupation

Employer

Race*

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian
White
Declined to Specify
Other Race

Ethnicity*

Hispanic or Latino
Not Hispanic or Latino
Declined to Specify

Language*

English
Spanish
French
Arabic

Height*

ft/in

Weight*

lbs

How did you hear about us?

Referral
Others in Family Have Been in
Online
Insurance Provider List
Other

If someone referred you, please specify who:

If other, please specify:

Date of most recent eye examination

Doctor who performed your most recent eye examination

City and State of most recent eye examination

Name of Primary Care Physician

Last Exam Date

Previous Eye Care

Please check all that apply

Full time glasses
Eye Surgery
Eye Medications
Low Vision Aid/Magnifiers currently used
Previous Low Vision Evaluation

If eye surgery, please specify the type of surgery:

If eye medications, please list:

If Low Vision Aid/Magnifiers are currently used, please specify:

If Previous Low Vision Evaluation, please specify the date and place:

Please check any of the following that apply to you:

General Health Problems:

Past severe head injury
Thyroid problems
Diabetes
High or low blood pressure
Headaches
Allergies
Sinus infections/pressure
Cataracts
Glaucoma

Primary Insurance Plan

Name of Insurance

Primary Insured Name

First Last

Relation to Patient

Insured ID Number

Group Plan Name/Number

Secondary Insurance Plan

Name of Insurance

Primary Insured Name

First Last

Relation to Patient

Insured ID Number

Group Plan Name/Number

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

Full Name	Relationship

Payment is due at the time services are rendered.

I will be paying today by:

Cash
Check
Credit/Debit Card (we accept Visa, Mastercard, American Express)
Care Credit

If you have insurance coverage for these services or materials and we are current providers, we will submit claims for you. However, we are not liable for collecting your claim. After 30 days, we will expect payment in full from you if your insurance company has not paid.

I hereby authorize my insurance carrier to make payment directly to Five Points Eye Care Center. I authorize that I am financially responsible for all charges whether or not they are covered by insurance or other entities. I also authorize release of any information regarding my treatment or condition in order to obtain payment for services.

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any services rendered. I have read all the information on this sheet and have completed the above questionnaire. I certify that this information is true and correct to the best of my knowledge. I agree to notify this office of any changes in my insurance status or the above information.

Patient Signature*

Date*

Parent/Guardian Signature (if minor)

Date