* * * PATIENT INFORMATION UPDATE* * *

Please fill in the following information:  (Please Print)

NAME___________________________________________________________ TODAY'S DATE________/_______/________

                LAST                                FIRST                         MIDDLE INIT.           TITLE

o NO CHANGE

DATE OF BIRTH____________________________________________ AGE___________________      SEX:   M     F

ADDRESS___________________________________________________________________________________________

                STREET ADDRESS         AND           PO BOX                    CITY                                                     STATE                                          ZIP

TELEPHONE (HOME)_______________________(CELL)________________________ (WORK)______________________

Email:__________________________________

SOCIAL SECURITY NUMBER:__________-__________-_________  REFERRED BY_______________________________

SPOUSE (OR PARENTS OR GUARDIAN)__________________________________________________________________

WHAT IS THE REASON FOR THIS VISIT?__________________________________________________________________

ARE YOU INTERESTED IN:_____CONTACT LENSES  _____GLASSES _____SUNGLASSES _____SPORTS GLASSES

                                             _____ REFRACTIVE SURGERY _____ OTHER______________________________________

INSURANCE:  MEDICARE  _________________________________   MEDICAID__________________________________

                                                    POLICY NUMBER                                                                                   POLICY NUMBER

o NO CHANGE

OTHER INSURANCE:  MEDICAL INSURANCE:_____________________________________________________________

                                                                            INSURANCE NAME AND POLICY NUMBER     

                                 VISION INSURANCE________________________________________________________________

                                                                          INSURANCE NAME AND POLICY NUMBER    

Insurance Disclaimer: Insurance benefits are determined on a claim to claim basis.  An insurance card and/or quote of insurance benefits is NOT A GUARANTEE OF PAYMENT.This office verifies all medical/vision benefits prior to seeing the patient. If for some reason beyond our control we can not verify benefits, you are held responsible for payment of services and materials rendered.

OUR PAYMENT POLICY

• EXAMINATION FEE IS DUE AT THE TIME OF THE EXAM
• AT LEAST ½ THE COST OF OPHTHALMIC PURCHASES ARE REQUIRED BEFORE ORDERS CAN BE PLACED
• BALANCE OF ACCOUNT IS DUE AT DISPENSING
• THERE IS A $30.00 SERVICE FEE ON ALL RETURNED CHECKS. WE DO NOT RE-DEPOSIT RETURNED CHECKS. WE ACCEPT VISA, MASTERCARD, AND DISCOVER CARDS

HOW DO YOU PLAN TO PAY TODAY?

________CASH   ________ CHECK  ________CREDIT CARD --__________________________________________________

                                                                                                 TYPE             CARD NUMBER                                                Exp Date           

DRIVERS LICENSE NUMBER:_________________________________________   

PLEASE READ THE FOLLOWING AND SIGN BELOW:

**INFORMATION RELEASE AND INSURANCE ASSIGNMENT**

I understand that I am personally responsible for payment of services and materials not covered by my medical/vision insurance and agree to do so.  I authorize Vision Plus Eyecare Center/Dr. Martin L. Habel to release any medical/vision information necessary to process my medical/vision insurance claims and/or to aid in further care of my eye health or vision status.  I authorize and request payment of medical/vision benefits directly to Vision Plus EyeCare Center/Dr. Martin L. Habel. I agree that my signature on this authorization form will cover all medical/vision services rendered until such authorization is revoked by me.  I agree that a photocopy of this form may be used in lieu of the original.

SIGNATURE:_____________________________________________________________________________________

                        PATIENT/PARENT/LEGAL GUARDIAN                                                                                                       OVER PLEASE Ù

Please answer these questions so that we may best meet your vision needs.

Do you use more than one pair of prescription glasses?____________________________

How much time do you spend out of doors during an average week?_________________       

Do you have sunglasses that filter out 100% of harmful UV light?___________________

Are you bothered by reflections or glare during the day or night?________

Are there times when you had rather not wear glasses?__________________

Are you interested in a contact lens test drive?_______________________

Would you be interested in glasses that are lighter, thinner, less noticeable, more comfortable?_________________________

In the past have you tended to scratch your glasses?__________________

Do you spend much time driving?____________________________

Do you have problems with glare from headlights when driving at night?___________

Do you work on a computer often?__________________________

Do you engage in sports or other activities that could put you at risk for an eye injury?______________ If so, what?____________________________

Do you have trouble seeing well enough to apply your make-up?__________