Patient Information Form - Auburn Lasik And Eye Institute printable pdf download

Patient Information Form - Auburn Lasik And Eye Institute

PATIENT INFORMATION FORM

PATIENT LEGAL NAME______________________________________________________

SS#________________________SEX_____________DOB_____________________________

MARITAL STATUS: SINGLE MARRIED WIDOWED DIVORCED

**NEW INFO REQUIRED BY FEDERAL ELECTRONIC HEALTH REGULATIONS

RACE/ETHNICITY____________________________________________

PREFERRED LANGUAGE______________________________________

HOME PHONE#________________WORK#________________CELL#_________________

E-MAIL ADDRESS____________________________________________________________

HOME ADDRESS_____________________________________________________________

CITY_________________________STATE____________________ZIP___________________

EMPLOYED BY:_______________________________________________________________

OCCUPATION_________________________________________________________________

EMERGENCY CONTACT_______________________________________________________

PHONE____________________CELL________________________WORK________________

INSURANCE & OTHER PHYSICIAN INFORMATION

INSURED LEGAL NAME_______________________________________________________

RELATIONSHIP TO PATIENT___________________ ________________________________

SS#__________________________DOB_________________ (FOR INSURANCE PURPOSES)

PRIMARY CARE (Family Doctor)

__________________________________________________

ENDOCRINOLOGIST___________________________________________________________

WHO MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE?

OPTOMETRIST________________________________________________________________

FRIEND/FAMILY_______________________________________________________________

OTHER_______________________________________________________________________

PRFERRED PHARMACY_______________________________________________________

AUBURN LASIK & EYE INSTITUTE

Patient Information Form - Auburn Lasik And Eye Institute