Patient General Consent & Financial Responsibility Form PATIENT’S LEGAL NAME* First Middle Last Date of Birth Date Format: MM slash DD slash YYYY NEW PATIENTRETURNINGINDIVIDUAL RESPONSIBLE FOR PAYMENT OF UNPAID BALANCESNAMERELATIONSHIP TO PATIENTFAMILY MEMBER OR OTHER PERSONS WE MAY INFORM ABOUT YOUR MEDICAL CONDITION/ DIAGNOSISNAMERELATIONSHIPPHONE NUMBER PATIENT’S BILLING INFORMATION Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HOME NUMBERMOBILE NUMBER*MAY WE SEND YOU TEXT MESSAGES FOR APPT UPDATES? (NO SPAM)YesNoEMAIL* MAY WE SEND YOU EMAILS WITH PRACTICE ANNOUNCEMENTS?YesNoEMPLOYERSOCIAL SECURITY NUMBERCan we leave confidential messages such as appointment reminders on the home, mobile, or email provided?YesNoSPECIFIC INSTRUCTIONSACKNOWLEDGEMENT OF PRIVACY PRACTICES NOTICE RECEIPT* I HAVE RECEIVED A COPY OF TSO NEW BRAUNFELS’ NOTICE OF PRIVACY PRACTICES WITH AN EFFECTIVE DATE OF MAY 13, 2020.PATIENT / PATIENT REPRESENTATIVEPATIENT / PATIENT REPRESENTATIVE SIGNATUREVISION PLAN NAMEMEMBER/SUBSCRIBER ID NUMBERMEDICAL PLAN NAMEMEMBER/SUBSCRIBER ID NUMBERPRIMARY INSURANCE HOLDER’S INFORMATION *ALL PATIENT INFORMATION IS STRICTLY CONFIDENTIAL. YOUR INFORMATION IS NEVER SHAREDNAMEDATE OF BIRTH Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PHONE NUMBEREMPLOYERSOCIAL SECURITY NUMBERPRIMARY CARE PHYSICIAN NAMEPRACTICE NAMEPlease Initial the Three Statements BelowSINCE OUR LAB BEGINS PROCESSING EACH ORDER FOR GLASSES IMMEDIATELY, WE ARE UNABLE TO MAKE ANY CANCELLATIONS AFTER THE ORDER HAS BEEN PLACED. LENSES ARE CUSTOM-MADE AND ARE NON-REFUNDABLE.*IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE BENEFITS (CO-PAYS, WHAT IS/IS NOT COVERED, ETC), PLEASE ASK PRIOR TO SEEING THE DOCTOR AND WE WILL ASSIST YOU THE BEST WE CAN. ANY APPLICABLE CO-PAYS AND PAYMENT FOR ITEMS NOT COVERED BY YOUR INSURANCE MUST BE COLLECTED AT THE END OF YOUR VISIT.*I UNDERSTAND THAT FOR A CONTACT LENS EVALUATION (ACCOMPANIES EVERY CONTACT LENS EXAM BY TEXAS LAW) THE EVALUATION FEE VARIES UPON DIAGNOSIS OF PRESCRIPTION.*IN THE EVENT THAT THE SPONSOR OF YOUR INSURANCE PLAN DETERMINES THAT YOU ARE NOT ELIGIBLE AT THE TIME OF SERVICE OR MAKES A DETERMINATION THAT YOU ARE ELIGIBLE FOR A REDUCED LEVEL OF COVERAGE, BY SIGNING THIS AGREEMENT YOU AGREE TO BE FINANCIALLY RESPONSIBLE FOR ANY AND ALL OF THE CHARGES INCURRED BY YOURSELF AND THE PLAN SPONSOR.PATIENT / PATIENT REPRESENTATIVE NAMEPATIENT / PATIENT REPRESENTATIVE SIGNATURE