Patient History Form

Name: Five Points Eye Care
Address: 698 S Milledge Ave, Athens, GA, 30605, US
Telephone: 706-543-2020
Price range: $000 - $300

Name
First Middle Last
Preferred name
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Social Security Number (last 4 digits only!)
Email
Address
Street Address Address Line 2 City State Zip Code
Primary Phone
Secondary Phone
Emergency Contact Name
Emergency Contact Phone
Children in Family
Name Age
Referred By
Family Member
- Yes
- No
Online
- Yes
- No
Insurance Provider
- Yes
- No
Other
- Yes
- No
Complete this section If patient is under 18 years of age
Parent / Legal Guardian Name
Parent / Guardian Social Sec. #
If student, grade 1-6, write school, grade and teacher's name
Please list any additional persons you authorize to access your personal health information (PHI), including billing and medical records information
Full Name Relationship
Race
- American Indian Or Alaska Native
- Native Hawaiian
- Asian
- White
- Black Or African American
- Declined To Specify
- Hispanic Or Latino
- Other Race
Ethnicity
- Hispanic Or Latino
- Not Hispanic Or Latino
- Declined To Specify
Language
- English
- Spanish
- French
- Arabic
Height
Ft In Cm/M
Weight
Occupation
Employer
Physician Details
Primary care physician
Last Exam Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Eye Care Physician's Name
Last Exam Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Insurance Plan
Name of Insurance
Insured Patient's Name
Insured Pt's ID Number
Group Plan Name / Number ID
Relation to Policyholder
- Self
- Spouse
- Child
- Other
Secondary Insurance Plan
Name of Insurance
Insured Patient's Name
Insured Pt's ID Number
Group Plan Name / Number ID
Relation to Policyholder
- Self
- Spouse
- Child
- Other

Name	Age

Full Name	Relationship

Referred By

Complete this section If patient is under 18 years of age

Physician Details

Primary Insurance Plan

Secondary Insurance Plan

Five Points Eye Care