Welcome To Advantage Optical Please print clearly the following information: Chart # Mr.   Dr.   Mrs.   Miss  _________________________________________________ Last First Street ______________________________________________________ City ____________________________ State _____ Zip Code _________ Telephone Number ________________Daytime Number ____________ Date of Birth _______________ Type of Insurance _________________ Patientfs Social Security Number _______________________________ Only if you have insurance Primary Insuredfs SSN# ______________________________________ Only if you have insurance Primary Insuredfs Name_________________________D.O.B.________ Only if you have insurance E-mail Address ______________________________________________ How did you hear about us? ___________________________________ PRIVACY PRACTICES ACKNOWLEDGEMENT I have received the Notice of Privacy Practices from Advantage Optical and I have been provided an opportunity to review it. Patient (or Legal Guardian) Signature _____________________________