New Patient Health History Form

Medical History

Family History

Social History

Review of Systems

Acknowledgement of Receipt of Notice of Privacy Practices

Signing this document signifies that you have received a copy of our Notice of Privacy Practices.

In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct healthcare operations involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail.

I acknowledge that I have received the Notice of Privacy Practices from Main Street Optometry.

If signing as a personal representative ofthe patient, describe the relationship to the patient and the source of authority to sign this form: