Looking Glass Eye Center Patient Information Form

  • Looking Glass Eye Center Patient Information Form

  • Date Format: MM slash DD slash YYYY
  • PERSON RESPONSIBLE FOR ACCOUNT (PARENT/GUARDIAN)

  • Date Format: MM slash DD slash YYYY
  • PLEASE PRESENT YOUR INSURANCE CARDS TO BE SCANNED AT TIME OF SERVICE

    I authorize Looking Glass Eye Center to release any information to any insurance company that may be needed to process an insurance claim for myself or my dependent. I assign any payable benefits to Looking Glass Eye Center. with or without insurance, I understand that I am responsible for all charges incurred while under the care of Looking Glass Eye Center.
  • Date Format: MM slash DD slash YYYY