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 _____________________________