Patient Information Form


Please answer these questions so we may better serve you.
Last Name* Gender  
First Name* Date of Birth*
Guardian if child Age
Title Social Security #
Nickname
Address* Employer
Address Occupation
City* Referred by
State   Zip* Date Last Exam
Home Phone* Cell Phone
Day Phone Pager
E-Mail Fax
Medical Insurance 1 Plan Name
HMO  PPO  POS  EPO 
 Co-Pay
Other Insured:   
Medical Insurance 2 Plan Name
HMO  PPO  POS  EPO 
 Co-Pay
Other
Insured:
  
Vision Insurance
Insured:
   
Insured Name Insured DOB
I request that insurance benefits be paid to Dr. Steensma. I allow the release of any personal information necessary to determine insurance benefits. I understand that Dr. Steensma’s office will verify insurance benefits as a courtesy. In the event of the insurance company denying benefits, I will be responsible for paying the charges. We hope that you will find your visit to our office to be a pleasant and interesting experience. If your eyes are dilated during this visit, your vision may be blurred and lights will be bright.
DO NOT LEAVE UNTIL YOUR VISION IS SAFE FOR DRIVING!
Name: Date:
Sign: Guardian Sign: