Anderson Eye Care

4171
  • ANDERSON EYE CARE
    GARY A. ANDERSON, O.D. • LISA M. SLADEK. O.D.

    RIVERFRONT PLAZA BUILDING • STE. 10 • 55 CAMPAU AVE. • GRAND RAPIDS, MI 49503-2817
    TEL: (616) 459 7380 • FAX: (616) 459 5752 • WWW.ANDERSONEYE.COM
  • Patient Information

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  • Insurance Information

    IMPORTANT NOTE: Please provide your medical and vision insurance card(s) to the receptionist. If you do not provide us with complete insurance information at the time of your Initial visit, we will be unable to bill your insurance company. You are then responsible for payment at the time of service.
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  • Medical History

    Do you have, or have you ever had, any of the following medical conditions?
  • Ocular History

  • (Prescription and over-the-counter, including eye drops)
  • Social History

  • Family History

  • By signing below, I verify that the above information is correct. I understand that I am responsible for all financial obligations for health services and for reimbursement and payment of claims from my insurance company.
    If, for any reason, the account should become delinquent, I agree to pay for all billing charges, interest charges, collections costs, and reasonable legal fees.
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