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PATIENT_INFORMATION_SHEET

VIEWS: 3 PAGES: 1

  • pg 1
									EYE CARE OF LEXINGTON                                                     EYE ASSOCIATES OF WINNSBORO
           602 East Main Street,∙ Suite C                                                        1007 Kincaid Bridge Road
                Lexington, SC 29072                                                               Winnsboro, SC 29180
                    803-359-2110                                                                      803-635-6496
                                                               Dr. Greg Bailey


                                                           PATIENT INFORMATION

                                                     PLEASE PRINT
Patient                                                           Home                 Business            Mobile
Name ____________________________________________________________ Tel. ________________Tel._______________ Tel. ____________
            (Last)                 (First)             (Middle)

Address __________________________________________________________________________________ Soc. Sec. # _____________________
          (Street)                           (City)              (State)        (Zip)

Date of Birth ________________________________ Age ____________ Sex __________
                (Month)   (Day)     (Year)

How did you hear of us? MD/Family/Yellow Pages/Other ____________________Referring Dr. _______________________ Ph. _______________

Employer ______________________________________________________________________________ Occupation _______________________

Employer Address ________________________________________________________________________________________________________
                   (Street)                                    (City)                    (State)          (Zip)

Name of Spouse/Parent ____________________________ Spouse’s/Parent’s Employer _______________________ Telephone: _______________

In Emergency Contact ____________________________________________________________________________________________________
                      (Name)                                  (Relationship)                       (Telephone)
E-mail Address _________________________________________________________________________________________________________

                                                             RESPONSIBLE PARTY

Name ______________________________ Soc. Sec. # ________________                                            _____ Date of Birth _______________
                                                                                                                                (Mo.) (Day) (Year)
Address ________________________________________________________________ Home              Business         Mobile
         (Street)                         (City)       (State)    (Zip) Tel. _____________ Tel. ___________ Tel. ____________

Employer __________________________________ Address ______________________________________________________________________
                                                      (Street)                    (City)            (State)      (Zip)

                                                         INSURANCE INFORMATION

Primary Insurance ___________________________ Policy Number ______________________________ Group Number _____________________
Subscriber Name ____________________________ Soc. Sec. # ____________________Self  Parent Spouse/Date of Birth ________________
__
Secondary Insurance _________________________ Policy Number ______________________________ Group Number _____________________
Subscriber Name ____________________________ Soc. Sec. # _______________                                                ______
____
Tertiary Insurance ___________________________ Policy Number ______________________________ Group Number _____________________
Subscriber Name ____________________________ Soc. Sec. # ____________________                                                               ______

                                              MasterCard

Insurance coverage for your medical care is helpful since it reduces your potential liability, and we are glad to help you complete claim forms.
However, the financial agreement rests with you and not the insurance company. Patient’s or authorized person’s signature: I authorize the release
of any medical or other information necessary to process my insurance claims. I authorize payment of medi



Signature ___________________________________________________________________                                   Date ______________________

								
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