Patient Information Sheet

EMERGENCY CONTACT:

Name

Relationship

Phone

Do you have, or have you had any of the following (check all that apply)

Do any of your relatives have any of the above diseases? If so, which disease(s), and what is their relationship to you?

Check any that apply

I am now, or it is possible that I am pregnantI wear glasses or contact lensesI use eye drops

Date of last eye exam & performed by

Specify your eye drops

Medication Allergies (list any)

List all medications you are currently taking

By your signature below, you authorize us to bill your insurance company (if applicable) on your behalf for any covered services and agree to the release of medical information about you to your insurance company as necessary to process your claim.

Your signature below also confirms your agreement to pay for any non-covered and/or out-of-pocket responsibilities such as co-pays and deductibles, at the time service is rendered.

PATIENT IS RESPONSIBLE TO VERIFY PROVIDER PARTICIPATION IN INSURANCE PLAN AND TO OBTAIN ANY REQUIRED INSURANCE AUTHORIZATIONS PRIOR TO VISIT.

Signature

Clear

Date

Patient Information Sheet

Medical Information