Welcome To Advantage Optical
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Please print clearly the following information: Chart #
Mr. ?  Dr. ? 
Mrs. ?  Miss?  ______________________________
Last \t First
Street ________________________________________________ State ___ Zip Code ______ _________Daytime Number _______

Date of Birth _________ Type of Insurance ____________________________
Only if you have insurance_____________________
Only if you have insurance _______________D.O.B.____
Only if you have insurance

E-mail Address _________________________________________________________________

City _

Telephone Number _

Patient?fs Social Security Number _

Primary Insured?fs SSN# _

Primary Insured?fs Name

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 _