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New Patient Iformation Form – ArmanArman Penilla2021-06-25T20:07:13+00:00

[5232] Training Cover Reg Form 1

Name(Required)
Sex(Required)
Date of Birth(Required)
Address(Required)
Texting is ok?
Note: We do not share your email address or phone numbers
Email is ok?
Employment Status(Required)
Emergency Contact Name
Do you currently wear contact lenses?
Consent
There are fees to evaluate and update a contact lens prescription. I understand that these fees are not covered by most insurance, vision, or managed care plans as it is not considered part of a routine eye exam. I will notify the staff if I decide not to have this service performed.

I understand and agree that health insurance policies are an arrangement between an insurance carrier and myself. I authorize payment from my insurance carrier direct to this office with the understanding that all monies will be credited to my account of receipt. However, I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I also authorize release of any medical information that may be required in determination of benefits. I have received a copy of Vision Source's Privacy Statement.
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