Welcome To The Vision Source

Vision Source is dedicated to patient satisfaction through excellence in eye

health care; knowledgeable, friendly service; and the finest eyewear products available.

Today’s Date: ______________________

Patient’s Name__________________________________________________________

Address________________________________________________________________

City_____________________________ State _________________Zip Code_________

Primary Phone _____________Secondary Phone _____________ Alternate Phone___________

Email Address___________________________________________________________

Patients Social Security Number___________________

Employer/School________________________ Occupation/Grade________________

Date of Birth____________________ Age_________ Sex   M    F

Name of your family physician_____________________________________________

            What is the major purpose of this visit?

                            _______________________________________________________________________________

            What problems do you have with your current contacts or glasses?

                            _______________________________________________________________________________

            Whom may we thank for referring you to our office?

                            _______________________________________________________________________________

            How did you hear about our office?

                            Another Doctor                    Vision Insurance                  Newspaper                            Location

                            Yellow Pages                        Insurance List                       Radio/TV                               Other

            How will you settle your account today?                         Person Responsible for Account________________

                            Cash                       Check                     Credit Card

Please read below and sign.

            In the course of providing service to you, we create, receive, and store health information that identifies you.  It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct

health care operations involving our office.

            We have a comprehensive Notice of Privacy Practices that describes these uses and disclosure in detail.  You are free to

 refer to this Notice at any time before you sign this consent document.

            When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations.

            I hereby authorize Vision Source Alexandria to apply for benefits in my behalf for covered services.  I agree to assume responsibility for full payment of any remaining balance that is not covered by my insurance.

Signature: _____________________________________ Relationship to patient: _____________________________