HOW DID YOU DECIDE TO COME TO OUR PRACTICE?
*We abide by all HIPPA privacy regulations and do not sell or market your demographic information, including your e-mail address, to anyone.
INSURANCE INFORMATION
Financial Assignment Information: I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will immediately due and payable to Lentz Eye Care.
MEDICAL HISTORY
FAMILY HISTORY
Please note any personal or family history (parents, grandparents, siblings, children, living or deceased) for the following conditions.
SOCIAL HISTORY
REVIEW OF SYSTEMS
Do you currently, or have you ever had any problems in the following areas:
CONSTITUTIONAL
NEUROLOGICAL
EYES
ENDOCRINE
EARS, NOSE, MOUTH, THROAT
RESPIRATORY
VASCULAR/CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
BONES/JOINT/MUSCLES
LYMPHATIC/HEMATOLOGIC