Patient Information

Name *

Social Security # *

Date of Birth *

Email Address

Cell Phone

Employer *

Phone Numbers & Contact Information

Is there anyone you would like to list that can have access to your personal health information? If so, please list below:

Name

Phone #

Name

Phone #

Lifestyle Questions

Do you....(check "yes" or "no") *

	Yes	No
...use a computer or smartphone?	Yes	No
...enjoy hunting, fishing or shooting sports?	Yes	No
...have a backup pair of eyeglasses?	Yes	No
...have a skin reaction to nickel or costume jewelry?	Yes	No
...have interest in trying contact lenses?	Yes	No
...have fluctuating vision problems that improve when you blink?	Yes	No
...have a separate pair of sunglasses?	Yes	No
...want to consider new glasses today?	Yes	No

Assignment & Release of Benefits/Privacy Notice

I acknowledge that I have been given the opportunity to review Eye Health Solutions Notice of Privacy Practices.

Name

Date

By entering your name and date in the above fields, you are digitally signing this document.

I, the undersigned, cerifty that I (or my dependent) have the insurance coverage with the company named below and assign directly to Eye Health Solutions all insurance benefits, if any, otherwise payable benefits for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Eye Health Solutions to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Insurance Coverage Company

Name

Date

By entering your name and date in the above fields, you are digitally signing this document.

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