Patient information

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Billing information

If yes, please provide the billing address information below

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


Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.

Financial Policy / Medicare Acknowledgment

View Financial Policy Form

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Notice of Privacy Practices

View Notice of Privacy Practices Form

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Patient Record Of Disclosure

The HIPAA privacy rule gives individuals the right to request a restriction on notes and disclosure of their Protected Health Information (PHI). The individual is also granted the right to request confidential communications, or that a communication be made by alternative means.

I wish to be contacted in the following manner: (Check ALL that apply)

It is ok to leave me a message with detailed information on my home telephone.

It is ok to leave me a message with detailed information on my cell phone.
It is ok to send me a text message with detailed information on my cell phone.


It is ok to leave me a message with detailed information on my work phone.
It is ok to leave a call back number only at my work number on my work telephone.

I would prefer to be contacted on my:

I authorize you to discuss my medical history and release any and all medical information to the following individuals.






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