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Discerning Eyeadmin2017-07-06T01:14:25+00:00

Discerning Eye

  • Patient Information and Medical History Questionnaire

  • If under 18 years of age
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • HomeWorkCell
  • MM slash DD slash YYYY
  • Ocular History

  • MM slash DD slash YYYY
  • Family History

  • Medical History

  • MM slash DD slash YYYY
  • Social History

    This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
  • Review of Systems

    Do you currently, or have you ever had any problems in the following areas:
  • Authorization

    I certify that I have read and understood the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the eye doctor to release any information including the diagnosis and the records of treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request that my insurance company to pay directly to pay directly to the eye Doctor insurance benefits otherwise payable to me. I understand that my eye care insurance may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
  • MM slash DD slash YYYY
  • HIPAA Consent

  • MM slash DD slash YYYY
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