Patient Information
Title:
First Name *
Your answer
Last Name *
Your answer
Preferred Name
Your answer
*
*
Date of Birth *
MM
/
DD
/
YYYY
Street Address *
Your answer
City *
Your answer
Zip *
Your answer
Preferred Phone Number *
Your answer
*
Alternate Phone Number
Your answer
Email
Your email may be used to remind you about appointments and to let you know your glasses or contacts are ready to be picked up. You may opt out of these communications at any time.
Your answer
Parent's Names
(if a minor)
Your answer
Occupation
Your answer
Employer
Your answer
Employment Status
Student Status
How did you hear about Blink Eyecare? *
If it was a personal recommendation and you would like us to thank them, please add their name in "Other".
When was your last eye exam?
(an estimate is acceptable)
MM
/
DD
/
YYYY
Where was your last eye exam?
Your answer
Vision Insurance Information
A vision care plan typically covers routine vision exams. It may also cover materials, such as glasses or contact lenses.
Vision Insurance *
Contract or Policy Number
(If your insurance is VSP, you may give us the last 4 of your Social Security Number if you do not have a Contract Number.)
Your answer
Subscriber's Name
(if different from patient)
Your answer
Subscriber's Date of Birth
(if different from patient)
MM
/
DD
/
YYYY
Subscriber's Address
(if different from patient)
Your answer
Medical Insurance Information
Medical care plans cover the treatment and management of eye diseases and screening for eye diseases if you have certain systemic conditions. This type of insurance is often used for eye problems such as dry eye, allergies, or red eyes.
*Please bring Medical Card to your appointment*
Medical Insurance *
Contract or Policy Number
Your answer
Subscriber's Name
(if different from patient)
Your answer
Subscriber's Date of Birth
(if different from patient)
MM
/
DD
/
YYYY
Subscriber's Address
(if different from patient)
Your answer
The following information is requested in order to comply with healthcare guidelines.
Preferred Language
Race
Ethnicity
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