Print This Form and bring it along to speed up your checking in process!!

Attention: Please take note: By signing below I am indicating my understanding of this
office's privacy practices. Also, I understand that if my insurance carrier does not pay all
charges in full, I will be responsible for the remaining balance due to Dr. Blondin.
This office no longer submits to secondary insurance companies. Primary insurance submitted
at the time of the visit is the only insurance that will be accepted and cannot be submitted or
changed after the patient is seen. And finally there is no refund on prescription eyewear.

Patient Information Sheet
Matthew Blondin, O.D., F.A.A.O.
379 Prospect Street, Suite B
Torrington, CT 06790 860-489-2781

We appreciate you taking the time to fill out all
information applicable on this sheet. Thank you.

Patient Full Name: __________________________
Gender: Male: _____ Female: _____
Address: __________________________________
_________________________________________
_________________________________________
Phone: (___)___________Work: (___)___________
Date of Birth : _____ / _____ / _____
Social Security Number: _______________________
Family Doctor:_______________________________
Phone: (______)____________________________

Signature: ___________________ Date: ___ / ___ / ___

If Minor, Responsible Party:
Name: _________________________________________
Telephone: (____)________________________________

Next Visit Date:___ / ___ / ____ Signature: ____________________
Next Visit Date:___ / ___ / ____ Signature: ______________________
Next Visit Date:___ / ___ / ____ Signature: ______________________