Patient information

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Billing information

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Primary Vision Insurance

Primary Medical Insurance

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Eye History

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Contact Lens Wearers Only


Family Eye History

Does anyone in your family have any of these eye conditions?





Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Review Of Systems

Social History

Policies, Consent, Submit Data



Notice Of Privacy Practices



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FINANCIAL RESPONSIBILITY

I acknowledge that I am responsible for all charges for services and materials provided, including the amount not covered by insurance plans. All services and materials provided are due and payable at the time of service or order. I understand that my insurance policy is an agreement between me and my insurance company. If payment from my insurance company is insufficient to settle my bill in full, the remaining balance and payment will remain my responsibility. All monthly statements are due and payable within 30 days. Any outstanding balances, after 30 days will accrue at a 1.5% monthly late fee. If my account remains unpaid after 120 days and payment arrangements were not made prior, my account may be placed into collections or small claims court.



AUTHORIZATION TO ASSIGN INSURANCE BENEFITS

I authorize billing and payment of medical benefits to Laguna Eyes Optometry, P.C. and Slow the Game Down for all services rendered during my visit. I understand that I am financially responsible for all charges, whether or not theses are covered by my insurance. I authorize Laguna Eyes Optometry, P.C. and Slow the Game Down to release all information necessary to secure payment from my insurance company on my behalf.



Communication Preferences



I approve Laguna Eyes Optometry, PC to communicate with the following people about my eyecare and/or release my products to the following people without prior authorization:







Emergency Contact(This Person To Be Contacted In Medical Emergency.)