Thank you for choosing us for you eye care needs. We are delighted to have you as a patient and appreciate the confidence you have placed in us. Please take a moment to complete the following information. Any information we already have on file will appear on this form. Please review all completed areas to ensure that the information we have is current and accurate. If you have any questions, please do not hesitate to ask.

Appointment Date

Name

First Middle Last

Date of Birth

Social Security Number

Occupation

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Home Phone

Work Phone

Email Address

Spouse or Parent(s) Name(s)

Primary Care Doctor

Primary Care Dr. Phone Number

Person Responsible for Account

Responsible Party SS Number

Date of Birth

Employer/School

Responsible Party’s Employer

Responsible Party’s Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Preferred method of contact:

Text
Email
Landline

IF NO CHANGES TO YOUR INFORMATION, PLEASE INITIAL HERE

Vision Insurance Information

Company

ID#

Group

Subscriber’s Name

Subscriber’s DOB

Subscriber’s Employer

Patient Relationship to Insured

Self
Spouse
Child

Medical Insurance

Company

ID#

Subscriber’s Name

Subscriber’s DOB

Authorization for dilation

In the process of today’s examination, the doctor may recommend dilation for further examination of your eyes. Dilation may not be part of the routine examination, thus it may be an additional expense. If so, do you wish to be dilated today?

Yes
No

Authorization to Release Medical Information

I authorize Robert M. Barton, Jr. O.D. to release/request medical information on my behalf to/from any entity to assist in my medical care per my request. This assignment will remain in effect until revoked in writing.

Yes
No

Patient/Guardian Signature

Date

Welcome to the office of Dr. Robert M. Barton, Jr.

Vision Insurance Information

Medical Insurance

Hours & Directions

Vision Insurance Information

Medical Insurance

Hours & Directions

Schedule an Appointment