Annual Patient Information Step 1 of 2 50% Today’s Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Age M F SS#Patient Name First Last Email Address Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork PhoneCell Phone Emergency Contact: Name First Last Relationship PhoneOccupation: Current Medications (RX or over the counter)Consent I provided a separate medication listlist all medications including eye drops, vitamins & contraceptives below Add RemoveAllergies to medication (please list) Add RemoveAre you a smoker? Yes No Drink Alcohol? Yes No Name of Pharmacy of Choice: Name of family physician/practitioner First Last Date of last visit: MM slash DD slash YYYY Financial Policy / Insurance InformationWe ask that all patients read and sign our financial policy prior to seeing the doctor. 1. Payments and all co-payments are due at the time of service. Please indicate your preferred method of payment today: Check/Cash Credit Card (Visa, Master, American Express or Discover Care Credit 2. You will be responsible for all charges that are not covered by your insurance due to co-payments or deductibles. 3. There are no refunds for examinations, treatment, services or material purchases. 4. There will be a $30.00 fee for all returned checks and/or turning an account over to our collection agency and additional interest fees may also apply to accounts older than 60 days.About Your Vision and Medical InsuranceThere are two types of third party payors that will help pay for your eye care services and products. You may have both and our practice accepts both. The choice of which to bill is driven by your medical and eye history and/or your symptoms or issues brought up during the exam.Please initial your understandingAssignment and Release: I hereby authorize third party or insurance payments to be made directly to Accent Vision Specialists and fully understand that I am the responsible party for all fees incurred by me at the above mentioned facility. I also authorize the release of any information required for the processing of those claims. I, the undersigned, have read and agree to the above policies.Signature Patient (Parent or Guardian if minor) Date MM slash DD slash YYYY