ADRIAN EYECARE & OPTICAL

                                                                                                                                                                           DATE________________________

(Please Print)

PATIENT NAME  

_______________________________________________________________  M (  )   F  (  )

               (FIRST)                  (MIDDLE)                             (LAST)

STREET ADDRESS ___________________________________________________

PHONE (     ) _________________________

CITY/STATE/ZIP  _____________________________________________________

CELL (       ) _________________________

SOCIAL SECURITY NUMBER _______________________________ 

AGE ______       DATE OF BIRTH _________________

SINGLE ____        MARRIED _____ DIVORCED _______ WIDOWED ______ 

RACE:  CAUCASIAN ___  AFRICAN AMERICAN ___ HISPANIC ___  ASIAN ___ OTHER _________________

PREFERRED LANGUAGE ______________________________

COMMUNICATION PREFERENCE:   MAIL ___  TELEPHONE ___   EMAIL ___  OTHER __________________

EMAIL _____________________________________________________________________

FAMILY PHYSICIAN ___________________________    

PHARMACY & LOCATION________________________________

PATIENT EMPLOYER ____________________________________________ 

OCCUPATION __________________________

EMPLOYER ADDRESS _____________________________________

CITY ________________ PHONE _________________

NAME OF SPOUSE _________________________________________

DOB ______________ SS# ______________________

SPOUSE EMPLOYER _________________________________________

CITY ______________ PHONE ________________

EMERGENCY CONTACT (OTHER THAN SPOUSE):

NAME __________________________________________RELATIONSHIP ___________ PHONE______________________

IF YOU ARE UNDER 18 AND/OR A DEPENDENT, PLEASE COMPLETE THE FOLLOWING:

NAME OF FATHER ______________________________________ 

SS# __________________ DOB  _________________

ADDRESS IF DIFFERENT _________________________________________________________________________

CITY _________________ STATE _______PHONE __________________________

CELL __________________________

FATHER’S EMPLOYER _________________________________________ 

EMPLOYER PHONE ____________________

NAME OF MOTHER _____________________________________ 

SS# ____________________ DOB ________________

ADDRESS IF DIFFERENT _________________________________________________________________________

CITY __________________  STATE ______ PHONE _________________________

CELL __________________________

MOTHER’S EMPLOYER ___________________________________________ 

EMPLOYER PHONE _________________

PLEASE READ AND SIGN THE FOLLOWING RECORDS RELEASE, INSURANCE AUTHORIZATION AND ASSIGNMENT, AND RESPONSIBILITY AGREEMENT:

I authorize release of medical information to my doctor who referred me to this office.  I request that payment of my insurance or Medicare benefits be made to me or on my behalf to Adrian Eyecare & Optical for any services provided by them.  I authorize you to release to the insurance company and the centers for Medicare and Medicaid services my medical or other information needed to determine these benefits.  This request is effective until revoked by the patient.  If deemed necessary, I authorize this information to be sent via fax transmission.

I understand that I am responsible for all fees for professional services, including any balance remaining after my insurance benefits are paid.  Should I neglect to pay for services provided, I hereby agree to pay to Adrian Eyecare & Optical any actual costs of collection of my account, including all collection bureau charges or fees and any attorney fees.

SIGNATURE ___________________________________________________________   DATE ______________________