Patient Information

Phone Numbers & Contact Information

Is there anyone you would like to list that can have access to your personal health information?  If so, please list below:

Lifestyle Questions

Do you....(check "yes" or "no") *
 YesNo
...use a computer or smartphone?
...enjoy hunting, fishing or shooting sports?
...hve a backup pair of eyeglasses?
...have a skin reaction to nickel or costume jewelry?
...have interest in trying contact lenses?
...have fluctuating vision problems that improve when you blink?
...have a separate pair of sunglasses?
...want to consider new glasses today?

Assignment & Release of Benefits/Privacy Notice

I acknowledge that I have been given the opportunity to review Eye Health Solutions Notice of Privacy Practices.
By entering your name and date in the above fields, you are digitally signing this document.

I, the undersigned, cerifty that I (or my dependent) have the insurance coverage with the company named below and assign directly to Eye Health Solutions all insurance benefits, if any, otherwise payable benefits for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurance.  I hereby authorize Eye Health Solutions to release all information necessary to secure the payment of benefits.  I authorize the use of this signature on all insurance submissions.
By entering your name and date in the above fields, you are digitally signing this document.

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