<p> Welcome to Denville Family Eyecare</p><p>Patient Information</p><p>Thank you for choosing our practice for your eyecare needs. Please complete this form. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.</p><p>Please Print</p><p>Patient Name ______Date ______</p><p>Address ______City ______State ______Zip ______</p><p>Home Phone: ______Cell Phone :______</p><p>Work Phone: ______Email : ______@ ______</p><p>Patient’s DOB: ______Sex M F Patient’s Social Security# ______</p><p>Patient Status: (circle one) Minor Employed FT Employed PT FT Student Not Employed Retired</p><p>Insurance Information</p><p>Health Insurance Company: ______ID# ______</p><p>Name of Insured: ______Relation to Patient: ______</p><p>Insured DOB: ______Insured SS# ______Employer: ______</p><p>Vision Insurance Company: ______ID# ______</p><p>Name of Insured: ______Relation to Patient: ______</p><p>Insured DOB: ______Insured SS# ______Employer: ______</p><p>Please list any and all medications you are currently taking:______</p><p>______</p><p>Do you currently wear glasses? YES NO for: Distance Reading Computer Bifocal Progressive </p><p>Do you wear contacts? YES NO Are you interested in contacts? YES NO</p><p>What type of contact lenses do you wear? ______</p><p>By signing this document you attest that all the information you’ve provided is true.</p><p>X ______Date: ______</p>