Online Patient Forms

Patient information

First name

*This field is required

Last name

*This field is required

Nickname

Birth Sex

Male Female

Address

*This field is required

Apt/Suite #

City

*This field is required

State

*This field is required

Zip Code

*This field is required

Cell Phone

*This field is required

Home Phone

*This field is required

Preferred Contact Method

Birthday

*This field is required

SSN

Occupation

Employment Status

Employed

Fulltime Student

Parttime Student

Employer/School Name

Pronoun

Gender Identity

Marital Status

Misc/Guardian

Billing information

Is The Billing Address Different? Yes

If yes, please provide the billing address information below

Title

First

Last

Middle

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Primary Medical Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Primary On Account:

Name:

Relationship To Insured:

Spouse Child Other

Birth Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Primary Vision Insurance

Insurance Information

Insurance Name:

Insurance Plan:

Insurance ID:

Insurance Policy Group:

Not Primary On Account: Not Primary

Name:

Relationship To Insured:

Spouse Child Other

Sex:

Male Female

Address:

City:

State:

Zip Code:

Phone Number:

Birthday:

SSN:

Employer/School:

Policies, Consent, Submit Data

Assignment Of Insurance

Date

Patient Name:

* I , hereby assign and request that payment of all medical benefits be made to Center for Vision and Learning. I authorize the release of all medical and other information that is necessary to process claims. I understand that I am financially responsible for any and all non-covered charges incurred while under the care of said physician, including co-payments. It is also acknowledged that any unpaid balances may be subject to collections and is the responsibility of the guarantor.

*Patient or Responsible Party's Signature:

*Date

*Relationship to Patient:

Privacy Policy

**View HIPAA Patient Privacy Policy Form**

* I acknowledge that I have received a copy of the Notice of Privacy Practices from Davidson Optometry, P.C.. I have listed individuals that are authorized to receive my protected health information. I am aware that I can revoke the authorization for any individual at any time, but must do so in writing.

*Signature Of Patient:

*Date

*Signature of Patient Representative & Relationship Date:

*Date

(Required if patient is a minor or an adult unable to sign form)

The following individuals have my authorization to access my Protected Health Information

Name:

Relationship:

Date Of Birth:

Name:

Relationship:

Date Of Birth:

Name:

Relationship:

Date Of Birth:

Patient information

Billing information

Primary Medical Insurance

Primary Vision Insurance

Medical Information

Have You Received Any Of The Following Examinations? Check Any That Apply And Type In The Name Of The Provider.

REVIEW OF SYSTEMS

FAMILY HISTORY - Unknown Family History

Social History

Developmental History

OTHER SYMPTOMS (FOR CHILDREN IN ADDITION TO THE PREVIOUS SYMPTOMS)

Head Injury / Stroke History

Policies, Consent, Submit Data

Assignment Of Insurance

Privacy Policy

The following individuals have my authorization to access my Protected Health Information