Returning Patient Form

Welcome back to Optometry Care Santa Barbara

Please update any changes to the following information

If you have any questions, please call: 805-569-2318

Name

First Name

Last Name

Birthdate

YYYY

Current Address

Phone

(###)

###

####

Vision Insurance Provider, Insured Member Name & Member ID# (if applicable)

If you have medical insurance and you are unsure if it has an associated vision plan, please contact your insurance company to confirm who they subcontract their vision insurance to (VSP, EyeMed, Blue View, etc.) For Medicare Enrollees, please input your Member ID and name as shown on your insurance card. Input Secondary Health Insurance Policies as well **Please bring in your cards to visit**

Preferred Pharmacy and Location

Occupation

If retired what was your former occupation?

Hobbies

How do you use your eyes when you're not at work?

How many hours a day are you on your phone/ computer/ tablet/ device?

0-4 hours

4-8 hours

8-12 hours

12+ hours

Please provie an updated list of medical conditions

Name of primary care doctor & date of last physical

Please estimate if unknown

Updated Family History: any new diagnoses within your intimate family?

Please list the condition and respective family member

Updated list of medications, vitamins and supplements

New allergies to medications or foods? Please list

Assignment and Release: I hereby authorize that my insurance benefits be paid directly to Optometry Care Santa Barbara, and I am financially responsible for non-covered services. I also authorize the release of any information required to obtain these benefits.

By signing below, I consent to the no-show policy: We require a minimum of 24 hours notice for rescheduling or canceling an appointment. Any patient who fails to communicate the need for reschedule or cancellation will incur an $80 no show fee. In addition, if you arrive more than 15 minutes late to an appointment, this is considered a no-show and an $80 fee will be incurred.

I acknowledge that it is my right to receive my prescription upon completion of my eye examination and am under no obligation to purchase corrective eyewear.

I am consenting to a release of my records if deemed necessary by the doctor.

Date

YYYY