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LENTZ EYE CARE – WEST WICHITABerenice2021-05-14T19:13:39+00:00

LENTZ EYE CARE - WEST WICHITA

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  • HOW DID YOU DECIDE TO COME TO OUR PRACTICE?

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  • *We abide by all HIPPA privacy regulations and do not sell or market your demographic information, including your e-mail address, to anyone.

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  • INSURANCE INFORMATION

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  • 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.

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  • MEDICAL HISTORY

  • FAMILY HISTORY

    Please note any personal or family history (parents, grandparents, siblings, children, living or deceased) for the following conditions.

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    SOCIAL HISTORY

  • REVIEW OF SYSTEMS

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

     

    CONSTITUTIONAL 

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    NEUROLOGICAL

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    EYES

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    ENDOCRINE

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    EARS, NOSE, MOUTH, THROAT 

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    RESPIRATORY 

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    VASCULAR/CARDIOVASCULAR 

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    GASTROINTESTINAL

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    GENITOURINARY 

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    BONES/JOINT/MUSCLES 

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    LYMPHATIC/HEMATOLOGIC

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