Eyes Plus, Inc.

  • Patient Information

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  • Insurance/Responsible Party

  • Health History

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  • Authorization

  • I certify that the information given above is to the best of my knowledge. I understand that giving incorrect information could be hazardous to my health. I authorize Dr. Henry Makini of Eyes Plus, Inc. to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to a third party payer and/or health practitioner. I authorize and request my insurance company to remit payment directly to Dr. Henry Makini of Eyes Plus, Inc. otherwise payable to me. I understand that my eye care insurance carrier may pay less than the actual bill for services and I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that Dr. Makini and staff will be contacting me for any necessary follow-up appointments and/or annual visits in an effort to maintain continued quality of care of my visual health needs.
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