Patient #: ______________ Date: ______________ Time: ___________ Doctor: ________________

Patient Information

Name: ________________________________________________________________ Sex: F M

Address: ___________________________________________________ Marital Status: S W D M

City: __________________________ State: ______ Zip: __________ Date of Birth: _____________

SS#: __________________________ Co-Pay ___________ Age: ___________ Race: ____________

Home Phone: ___________________________ Work Phone: _______________________________

Person to notify in case of emergency:

Name: ___________________________ Phone #: ________________ Relation: ________________

Responsible party

Name: ___________________________________________________ SS#: _____________________

Address: ___________________________________________ City/State/Zip: __________________

Phone #: __________________________________________________

Referring source: __________________________________________________________________

1. List any family members that are patients here:

____________________________________________________________________________________

2. Nature of problem(s): ______________________________________________________________

3. Employed by: _____________________________________________________________________

AUTHORIZATION TO RELEASE INFORMATION: I authorize INSTITUTE FOR TOTAL EYE CARE, P.C., to release any medical information necessary to process health insurance claims. I also authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for this service as described. ACKNOWLEDGEMENT OF RESPONSIBILITY: I understand that I am financially responsible to you for all professional services rendered, including but not limited to those services which are not covered by Blue Shield PMD/Medicare programs or other private and commercial insurance programs (co-payments, refractions, and/or deductibles). I also understand that if I have an HMO insurance and do not obtain the proper referral number prior to my visit, that I am financially responsible for any charges incurred. I understand that payments for these charges are due at the time of service. In the event of default, I agree to pay all collection costs, including a reasonable attorney fee. Also, I acknowledge receipt of ITEC's "Notice of Privacy Practices" and further authorize contacting me or leaving a message at the telephone numbers and address I have provided and to discuss with family members or care givers anything about my private health information.

PATIENT/PARENT/GUARDIAN-SIGNED __________________________________ Date: ___________