[5235] MGC Optical Solutions Form 1

New Patient Information Form
Name
How do you prefer to be addressed? (nickname, Mr./Mrs., Dr., etc)
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Mailing Address
Texting is okay
Emailing is okay
We do not share your email address or phone numbers.
Employment Status
Do you currently wear contact lenses?

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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