1747 Medical Center Pkwy, Suite 130, Murfreesboro, TN 37129

New Patient Information Sheet

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Page 1 of 3

How did you hear about us?

If friend/family who:

Do you wear contact lenses?

Do you want an exam to become a contact lenses wearer?

Do you wear glasses?

Do you want new glasses today?

Are you interested in talking to the doctor about LASIK?

What is your preferred method of contact?

Phone

Mail

E-mail

(Used for appointment reminders and glasses/contacts pickup reminders)(We will never give out your Email or Phone numbers)

Page 2 of 3

Patient's Last Name

First Name

M.I.

Address:

City

State

Zip

Student?

Gender

Phone

Home #

Cellphone #

Work #

Emergency Contact

Name

Phone #

Relationship

Marital Status

Employer

Occupation

Primary Care Physician

Phone

RESPONSIBLE PARTY INSURED

Policy Holder name

Primary Ins

Relationship to Insured

Address

Same as patient

Others

Is the patient covered by any other Medical/ Vision insurance policy?

If yes, name of insurance

Assignment of Benefits: I agree to have my insurance send all payments for services rendered at Price Eyecare & Optical directly to the office on the claim form. Furthermore, I agree to have any medical records copied and sent to my insurance company to facilitate getting a claim paid and processed. This assignment may be copied and used the same as an original document. By signing the below, I acknowledge that all information is true and that I am compliant with the assignmnet of benefits. HIPAA- Patient Privacy Act* I hereby acknowledge that I received a copy of this medical practice's NOTICE OF PRIVACY PRACTICES. I further acknowledge that a copy of the current notice is posted in the reception area, and I will be offered a copy of any amended notice of Privacy Practices at each appointment.

SIGNATURE

Date

Member ID, SSN and DOB will need to be provided at time of check-in.

(ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)

Contact Us

1747 Medical Center Pkwy, Suite 130, Murfreesboro,TN 37129
priceeyecare@yahoo.com
(615) 896-7477
Andrea Price, Doctor Of Optometry
Tracy Patton, Doctor Of Optometry

©All rights reserved.Price Eyecare & Optical 2019