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 NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Age
SS#
Phone

Area CodePhone Number
Cell:

YesNo
Race
Ethnicity

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

Area CodePhone Number
If minor, name of Parent

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

First NameLast Name
SS#
DOB

MonthDayYear
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?

YesNo
If yes, Explain:
Personal Eye Operation

	Yes/No	Type	Left/Right	Date
Have you had any eye operations?
Have you had any eye injuries?

Family History: Please check all that apply

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

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Date

MonthDayYear
Signature

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Date

MonthDayYear
Signature

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Date

MonthDayYear
Signature

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Should be Empty: