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Patient Information
All information is strictly confidential and will not be shared except to verify benefits with your insurance company. In Focus Optometry has a business agreement with Google and you can rest assured that this form or any other Google form by our office is fully HIPPA compliant.  You can view our HIPPA privacy policy in the next pages.  To help us understand you and your eye health and visual needs, please fill out this form to the best of your knowledge.
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Email *
First Name *
Middle Name
Last Name *
Nickname
Please enter your nickname or a preferred name, if applicable
Birth Date *
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DD
/
YYYY
Gender *
Social Security Number  
This information is used for accounting and insurance verification purposes only
Race/Ethnicity
Address *
City *
State *
Zip *
Referred by
Phone Number (Home)
Phone Number (Cell)
Best way to reach you
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Marital status
Parent or spouse name
Emergency contact person - Name
Emergency contact person - Relationship
Emergency contact person - Phone Number
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