outpostoptical.com-Rabbitt Family Vision Center

Welcome to Rabbitt Family Vision Center

We appreciate the opportunity to care for your eye care needs! Please furnish us with the following information so that we may better serve YOU!
Name

First Name Middle Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth

Month Day Year
Age
SS#
Phone

Area Code Phone Number
Cell:

Yes No
Race
Ethnicity

Hispanic Non-Hispanic
Email Address
example@example.com
Emergency Contact:
Phone Number

Area Code Phone Number
If minor, name of Parent

First Name Last Name
List ALL Insurance:
ID#
Primary Card Holder Name

First Name Last Name
SS#
DOB

Month Day Year
Primary Card Holder 's Place of Employment
Has anyone in your household ever been a patient here? Who?
Has a specific problem brought you in to see us today?

Yes No
If yes, Explain:
Personal Eye Operation

Yes/No

Type

Left/Right

Date

Have you had any eye operations?

Have you had any eye injuries?

Yes/No

How many years

Diabetes

High Blood Pressure

High Cholesterol

Family History: Please check all that apply

N/A

Mother

Father

Brother

Sister

High Blood Pressure

Diabetes

Glaucoma

Macular Degeneration

Retinal Detachment

Cataracts

Authorization
I grant the following individuals permission to receive confidential information on my behalf:
By signing below, I acknowledge that the above information is correct to the best of my ability. I have also received Rabbitt Family Vision Center's Privacy Notice and the Cancellation/No Show Policy. I understand that whatever my insurance doesn't cover I will be responsible for.
Signature

Clear
Date

Month Day Year
Signature

Clear
Date

Month Day Year
Signature

Clear
Date

Month Day Year
Signature

Clear
Should be Empty: