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Becvar OptometryBerenice2021-08-24T21:07:03+00:00

Becvar Optometry

Patient History

Thank you for choosing us for your eyecare needs. We are delighted to have you as a patient and appreciate the confidence you placed in us. Please take a moment to complete the following information. Any information we already have on file will appear on this form. Please review all completed areas to ensure that the information we have is current and accurate. If you have any questions, please do not hesitate to ask.

Patient's Name

Name
MM slash DD slash YYYY

Patient's Address

Address
Primary Phone

Authorized to discuss health info Name:
Gender:
Marital Status:
Student

Primary Insurance

Insured's Name:
Insured's Address:
MM slash DD slash YYYY
Gender:
Pt Relationship to Insured:

Secondary Insurance

Insured's Name:
Insured's Address:
MM slash DD slash YYYY
Gender:
Pt Relationship to Insured:

Please Read:

НІРАА . I have reviewed or recieved a copy of Becvar Optometry's Health Insurance Portability and Accountability Act (HIPPA). By sigining below, I authorize the disclosure of my health information as described in the form.

MM slash DD slash YYYY

Digital Prescription Authorization

I give consent to receive a copy of my eyeglasses and/or contact lens prescription electronically.

Check one:
MM slash DD slash YYYY

Health History

Patient Name:
MM slash DD slash YYYY
Current Medications:
Please list all medications you are allergic to:
Do you smoke or use tobacco?
Current Eye Symptoms (Check all that apply to YOU)
Eye History (Check all that apply to YOU)
General Health Conditions (Check all that apply to YOU)
Family History (Check any condition that applies to your family (Parents, Grandparents, Siblings, Children; living or deceased)

Please answer the following questions about yourself:

Do you currently wear contacts?
Are you interested in wearing contacts?
Are you interested in laser eye surgery?
Are you interested in new glasses today?
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