Eyecare Consultants

  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Medical History

  • Date Format: MM slash DD slash YYYY
  • Family History

  • If my account requires servicing by a collection agency or by an attorney, I understand that I will be liable for the collection of fees, including reasonable attorney fees, and applicable court costs in addition to my outstanding balance. I understand that my insurance company has a contract with me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services tendered on my behalf or my dependents’. The policy of this office is that payment is expected at the time services are rendered.
  • Date Format: MM slash DD slash YYYY
  • Review of Systems: Eyes

  • Review of Systems: Ear, Nose and Throat

  • Review of Systems: Cardiovascular

  • Review of Systems: Constitutional

  • Review of Systems: Respiratory

  • Review of Systems: Gastrointestinal

  • Review of Systems: Genitourinary

  • Review of Systems: Psychiatric

  • Review of Systems: Endocrine

  • Review of Systems: Blood/Lymphnodes

  • Review of Systems: MusculoSkeletal

  • Review of Systems: Skin

  • Review of Systems: Neurological

  • Review of Systems: Immunologic