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FOCAL POINT VISION
PATIENT INFORMATION - PLEASE PRINT
Last Name: ______________________________ FirstName:_______________________________
Home Address: ________________________________________________ City/State/Zip: ______________________________________
Home Phone: ( ) __________--__________
Cell Phone: ( ) ___________--_________ Marital Status: S / M / D / W
E-mail address: ________________________________________________________________________________________________
Social Security: __________-_________-_________
Date of Birth _________/_________/_________ Age : ________ Sex: M / F
Employer: _______________________________________________________
Work Phone: ( ) _________--__________
Emergency Contact (other than spouse ) _____________________________________________________________________________
Home Phone: ( ) __________--__________
Cell Phone: ( ) ___________--_________
Work Phone: ( ) _________--________
Pharmacy Name: ________________________________________________ ( ) Local ( ) Mail Order
Address: ________________________________________________
City/State/Zip: ____________________________________________
Phone: ( ) --
Fax: ( ) --
How did you hear about us:
( ) Internet: www. ________________________________
( ) Dr. _______________________
( ) Newspaper ( ) Friend _______________________
( ) Yellow Pages ( ) Other _______________________
_________________________________________________________________________________________________________________
RESPONSIBLE PARTY / GUARANTOR
Name: __________________________________________________
First Name: ____________________________________________
Address: _____________________________________________________
City/ State/Zip _____________________________________
Home Phone: ( ) __________--__________
Cell Phone: ( ) ___________--_________
Work Phone: ( ) _________--________
Date Of Birth : _________/________/_________ Sex: Male___ Female ___
Social Security: _____________/___________/__________
Employer:
Employer Address:
PRIMARY INSURANCE INFORMATION
( ) Medicare ( ) Medicaid ( ) Other: Insurance Name: _____________________________________________
Name of Insured: Relationship: ( ) Self ( ) Spouse ( ) Child
SECONDARY INSURANCE INFORMATION
Insurance Name: ________________________________________________
Name of Insured: Relationship: ( ) Self ( ) Spouse ( ) Child
I hereby authorize my insurance company to pay directly to Focal Point Vision Correction, all benefits otherwise payable to me under the provisions of my policy. I hereby authorize the necessary medical information to be released to the insurance company for processing this claim and to be released to physicians or optometrists in connection with the continuity of care of patient. Photostat copies of this authorization will be considered as valid as the original.
Patient Signature: ______________________________________________ Insureds’ Signature: _____________________________
Today’s Date: ___________________________________
Medical Questionnaire 
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