Name*

(adults only, please specify title)

Title First Middle Last

Preferred Name

Date of Birth*

Social Security Number*

(last 4 digits only)

Primary Phone*

Secondary Phone

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name*

Emergency Contact Phone*

Children in Family

Name	Age

Referred By

Family Member
Online
Insurance Provider List
Other

If family member, please specify:

If online, please specify:

If insurance provider list, please specify:

If other, please specify:

Complete this section if patient is under 18 years of age

Parent/Legal Guardian Name

First Last

Parent/Legal Guardian Social Security Number

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

School

Grade

Teacher's name

Occupation

Employer

Email*

Primary Care Physician*

Last Exam Date*

City*

State*

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

Full Name	Relationship

Insurance Information

Primary Insurance Plan:

Name of Insurance

Insured Patient's Name

Insured Patient's ID Number

Group Plan Name/Number

Relationship to Policyholder

Self
Spouse
Child
Other

Secondary Insurance Plan:

Name of Insurance

Insured Patient's Name

Insured Patient's ID Number

Group Plan Name/Number

Relationship to Policyholder

Self
Spouse
Child
Other

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

PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED

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 understand that I am financially responsible for all charges whether ot 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 ot the above information.

Signature*

Date*

Parent/Guardian Signature (if minor)

Date