PATIENT INFORMATION FORM

DATE:_______________

Name: ______________________________________________________________________
(Please circle one: Mr. Mrs. Ms Miss M.D. D.D.S. Ph.D. D.O.)

Local Address: _______________________________________________________________
City:______________________________________State:__________ZIP Code:___________
Home Phone #:___________________________Work Phone #:________________________
Email Address:_________________________________

Mailing or "Summer" Address:___________________________________________________
City:______________________________________State:__________ZIP Code:___________
Phone #:_________________________________

SSN#:___________________________________Date of Birth:_________________________
Gender: Male Female Marital Status:___________________________
Name of Spouse:______________________

Occupation:______________________________Employer:____________________________
Work Address:______________________________________City:______________________
State:__________ZIP Code:______________Phone #:________________________________

In Case of an Emergency, we may contact:

Name:_________________________________________Phone #:_______________________
Address:_____________________________________________________________________
City:______________________________________State:___________ZIP Code:__________

Referred to our office by:_______________________________________________________

Insurance Carrier (If applicable):________________________________________________

***Please present all insurance cards to the front desk***
Please check with the front desk to make sure we participate in your insurance plan. Failure to do so may result in a denial from your carrier or payment out-of-pocket.

I hereby authorize Brems Eye Center to furnish information to insurance carriers concerning my illness and treatment, and I hereby assign to the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. I further permit a copy of this authorization to be used in place of the original.

DATE:________________SIGNATURE:__________________________________________

***If you have a secondary insurance, we need a second signature, giving us permission to submit your charges and diagnosis to your secondary insurance as well. Please sign below.***

DATE:________________SIGNATURE:__________________________________________