Rocky Mount Family Eye Care

  • Rocky Mount Family Eye Care Registration & Medical History

    We require payment in full/or insurance co-pays at the time services are rendered or eyewear is to be ordered. An insurance card must be presented at your visit to ensure proper billing.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Co-pays & deductibles are required on the date of service. We will bill your insurance but can't assure payment. You are fully responsible for payment. (Please give your insurance forms or cards to the front desk)

    *Professional fees are due at the time services are rendered. I will be responsible for charges to my family or me. Patients are responsible for all costs associated with collection or legal actions, including 33 1/3% attorney fees. Initial:
  • Initial:
  • perscription or over-the-counter
  • If insurance is filed on my behalf, I authorize my insurance benefits to be paid directly to Kartesz Family Eyecare Center.
    Initial:
  • I authorize the release of medical information to insurance carriers or other physicians if it is deemed necessary by any optometrist for financial or consultative purpose.
    Initial:
  • Date Format: MM slash DD slash YYYY
  • Name
  • Date Format: MM slash DD slash YYYY

  • Review of Systems

    Do you currently, or have you ever had any problems in the following areas: (If YES, please explain and list medications)

  • NEUROLOGIC

  • Eyes

  • EARS, NOSE, MOUTH, THROAT

  • RESPIRATORY

  • VASCULAR

  • GENITOURINARY

  • BONES/JOINTS/MUSCLES

  • LYMPHATIC/HEMATOLOGIC

  • ENDOCRINE

  • PSYCHIATRIC