Patient information

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Please enter only 10 digits, including the area code. Do not enter any dashes or spaces. Do not enter the number 1 in front of the phone number

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Type None if you Decline^

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If you don't have a Social Security Number, Please enter "None"

Billing information

If yes, please provide the billing address information below

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Medical History

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Eye History

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Note: Most insurance plans either: Do not cover Contact Lens Evaluation or Require a copay.

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

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Family Medical History

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


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Family Eye History

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


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Review Of Systems














Social History


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Notice of Privacy, Policies and Agreement


Patient acknowledges that


It is the patient's responsibility to check if we are out-of-network with their insurance plan prior to their visit.
It is the patient's responsibility to file insurance claims if we are not contracted with your insurance company.

I understand that all charges for professional services rendered are my responsibility. I understand this office, if contracted with my insurance company, will file a claim to my insurance company on my behalf.

I authorize payment of benefits to Eric Verret OD, Inc.

Your doctor will accept the fee approved by your insurance as payment in full for any covered services. The patient will be responsible for any amount approved but not paid by the insurance as well as the full amount for all non-covered services.

I agree to assume responsibility for co-payments and deductibles as specified by my insurance and for the charges of any non-covered services.

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NOTICE OF PRIVACY PRACTICES


Please read our Notice of Privacy

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices and that I will be offered a copy of any amended Notice of Privacy Practice at each appointment.

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RELEASE OF MEDICAL INFORMATION


I authorize release of my medical information to the following persons.


PHYSICIAN PATIENT ARBITRATION AGREEMENT


please read our Patient Arbitration Agreement

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