ULTRA VISION FAMILY EYE CARE

OFFICE VISIT NEW INTAKE

Name*

Prefix First Last Suffix

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone*

Please provide email address:*

Yes, I will
No, I decline

Email Address*

Symptoms*

Please select all that apply

Other*

Please explain other symptoms

Affected Area*

Please select all that apply

Other*

Please explain other area

Duration of Symptoms*

How long since the start of your symptoms?

Is this a work related injury?*

Yes
No, this is not a work related injury

Occupation*

CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

Health Information Protection*

I have read and agree to the Privacy Policy

I have received and read the office’s HIPAA policy above. A copy of the policy may be provided upon request.

ALL FEES ARE NON-REFUNDABLE AND MUST BE RENDERED AT TIME OF SERVICE

Patient Financial Responsibility*

I have read and agree to the Financial Policy

I have read the office’s financial policy above. A copy of the policy may be provided upon request. I guarantee payment of all charges incurred for the account of the above patient.

Name*

First Last

Signature*

I hereby release and assign the above vision insurance to Dr. Tam Ha, O.D. & Associates.

Date*