Patient Information

FOCAL POINT VISION

PATIENT INFORMATION -   PLEASE   PRINT   

                                                                                                                                                                                              First Name: _____________ Last  Name:________________   

Home Address: __________________City/State/Zip: ____________ 

Home Phone: (     ) ________-________ Cell Phone: (     )_____-_______ 

Marital Status: S / M / D / W        E-mail ____________

Social Security: __________-_________-_________

Date of Birth _________/_________/_________ Age :______ Sex: M / F

Employer: _____________________________________________________

Work Phone: (        ) _________--__________   

Emergency Contact  (other than spouse)_______________

Home Phone: (        ) __________--__________ 

Cell Phone: (       ) ___________--_________ 

Work Phone: (        ) _________--________

PHARMACY INFORMATION

Pharmacy Name: ____________________ ( ) Local          ( ) Mail Order

Address: ________________________________________________

City/State/Zip:___________________________

Phone: (    )_______ --________    Fax: (       ) ________--______

How did you hear about us:

(   ) Internet: www. ________________________________ 

(   ) Dr.      _______________________

(   ) Newspaper                                    (   ) Friend _______________________

(   ) Yellow Pages                                (   ) Other________________________

   RESPONSIBLE PARTY / GUARANTOR

Last Name ____________ First name ___________________ 

address:_________________________________________

City/ State/Zip _____________________________________ 

Home Phone: (        ) __________--__________

 Cell Phone: (       ) ___________--_________ 

Work Phone: (        ) _________--________ 

Date Of Birth : _________/________/_________ Sex: Male___ Female ___

Social Security: _____________/___________/__________ ­

­­­­Employer:_____________________ 

Employer Address: ____________________

PRIMARY INSURANCE INFORMATION

(   ) Medicare (   ) Medicaid (  ) Other: Insurance Name: ________________  Name of Insured:                                 Relationship: ( ) Self  ( ) Spouse ( ) Child

SECONDARY INSURANCE INFORMATION   

                                                                                                                                                                                                                   Name: ________________________________________________ 

 Name of Insured:                            Relationship: ( ) Self   ( ) Spouse ( ) Child

I hereby authorize my insurance company to pay directly to Focal Point Vision Correction, all benefits otherwise payable to me under the provisions of my policy. I hereby authorize the necessary medical information to be released to the insurance company for processing this claim and to be released to physicians or optometrists in connection with the continuity of care of patient. Photostat copies of this authorization will be considered as valid as the original.

Patient Signature: ______________________________________________

Insureds’ Signature:________________ 

Today’s Date:__________________ 

Medical Questionnaire