Patient information

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Billing information

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Primary Vision Insurance

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Primary Medical Insurance

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Medical History

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Eye History

Contact Lens Wearers only:

Medical History:

Do you have any of these medical conditions?

Family Medical History

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

Family Eye History

Does anyone in your family have any of these eye 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.

Notice of Privacy Practices

View Notice of Privacy Practices Form

Patient Record Disclosure

In general, The HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

I wish to be contacted in the following manner (check all that apply):


At the time of service, we request vision and medical insurance to be provided. The appropriate insurance will be filed depending on examination findings. Medical insurance may be filed for certain ocular conditions but not limited to the following: cataracts, glaucoma, red eyes, diabetes, retinal detachments, etc.

Payment Policy:

I hereby assign all medical benefits, including all major medical benefits to which i am entitled including Medicare, private insurance and any other health plans, to Gwinnett Pediatric & Adult Eye Center LLC. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment. If my insurance company has not reimbursed Gwinnett Pediatric & Adult Eye Center LLC within 60 days, Accurate Insurance must be provided at the time of service. After services have been rendered, the patient must file any insurance that is attempted to be used. An itemized list of services will be provided for self-filling. If the insurance company has disperesed a reimbursement for services, a credit will be applied to my account for future services. I may be billed for any services or products that I have received. I understand that I am responsible for the balances due after billing. I understand that a late fee of $5.00 may be charged if i do not pay my balance within 30 days after receiving my statement. I certify that my responses or exchangees and that all sales are final unless covered under manufacturer warranty or office warranty programs.