Welcome Form

Welcome to Eyebright Optometry!

PLEASE STAY IN YOUR CAR AND GIVE US A CALL WHEN YOU ARRIVE.

Per the department of health guidlines our healthcare clinic still requires masks to be worn at all times for ages 2 and older.
COVID 19 Screening Questions

In the last two weeks have you: (please answer for the patient if you are filling this form for someone else) Anyone with symptoms, or positive COVID test within in 2 weeks of your appointment we will need to reschedule your appointment.
Check All That Apply: *

In the past 14 days I have had a fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting or diarrhea? I have travelled in the past 2 weeks. I have tested positive for COVID-19 I have been around someone with COVID-19 symptoms and or with someone who has tested positive for COVID-19. I do NOT have any COVID-19 symptoms and have NOT had any exposure to anyone with these symptoms and have NOT tested positive for COVID-19 in the last 14 days.
Vaccination Status: Check all that apply *

Fully Vaccinated Partially Vaccinated Not Vaccinated Booster Shot
Date: *

Month Day Year
Date
Miss Mrs. Mr. Dr.
First Name *
Middle Name
Last Name *
Preferred name if different from above
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number (*NOTE due to new check in procedures please provide your mobile) *
Alternate Number
Alternate number type

Home Work
Email
example@example.com
Preferred contact method (check all that apply)

Email Mail Phone Text
Employer.
Occupation
Date of birth (patient) *

Month Day Year
Date
Last 4 of SSN *

HIPPA and Signatures
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) I read the copy of Eyebright Optometry Notice of Privacy (on the office website FORMS page) and understand I may request a copy of records. The Notice of Privacy Practices is subject to change. Update policies will be available at the front desk.
Signature *

Clear
I authorize the payment of health care benefits to this office. I understand I am responsible for payment of any charges not covered by insurance.
Signature *

Clear
I authorize any holder of medical information about me to be released and/ or request my medical information with other health care professionals for the purpose of consultation and referral as needed for my health care.
Signature:

Clear
Please print name if signing for a minor.
Name

First Name Last Name
Please check this box if you have read check-in procedures *

I have read check-in procedures
Should be Empty:

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COVID 19 Screening Questions

Vision Insurance