Returning Patient Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

Name*

Prefix First Last Suffix

Date of Birth*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Phone Number*

Please provide a telephone number, with area code, so we can contact you.

Do we have permission to leave voicemail?*

Yes
No

Do we have permission to send text messages and other communications?*

Yes
No

People with whom we can share your Protected Health Information (PHI)

Emergency Contact Name*

Emergency Contact Phone Number*

Please provide a telephone number with area code.

Someone authorized to make appointments and order or pick up glasses/contacts

Name

Relationship

Communication Preference

Please list any changes to medical or surgical history since last visit. If unable to recall what has been previously documented, please list all relevant medical conditions and surgeries. *

Changes to medications since last visit (new or discontinued). If unable to recall what has been previously documented, please list all current medications. *

Notes for the scheduling staff

Authorization for E-Mail Communication (Please note that this does not include Protected Health Information.)

Email Address

I hereby acknowledge that e-mail between Family Vision Solutions and me is not encrypted and therefore not guaranteed to be private. I grant permission for Family Vision Solutions to send newsletters, appointment reminders and appointment confirmations. I will notify Family Vision Solutions of any changes to my E-Mail listed here.

Privacy Policy

Health Information Protection*

I have read and agree to the Privacy Policy

Email

This field is for validation purposes and should be left unchanged.

RETURNING PATIENT FORM