Kid's Eye Site

  • Medical History Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Guardian/Alternative Contact Information

  • Insurance Information

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

    Personal/Family History Please indicate if the patient or any family members have a history of any of the following:
  • ANSWER IF UNDER 18:

  • Assignment of Benefits Authorization

    By signing below I understand that I am responsible for the balance on my account for any professional services rendered by Kid's Eye Site, regardless of my insurance status. I understand that it is my responsibility to pay any deductible amount, co-insurance or any remaining balance left unpaid by my insurance provider.
  • Notice of Privacy Practices

    By signing below I acknowledge that I have had the opportunity to read Kid's Eye Site's Notice of Privacy Practices and Financial Policy.
  • Date Format: MM slash DD slash YYYY