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SVS Vision – Patient Exam Formadmin2020-04-08T18:56:17+00:00

SVS Vision - Patient Exam Form

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  • Please be aware that the form below is for patients who have an upcoming appointment scheduled. If you do not have an appointment scheduled at this time and you would like to schedule one, please visit svsvision.com/contact or give your local office a call directly.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • If none, please type "none"
  • If none, please type "none"
    Please check all that apply
  • Please list all concerns that you want to have addressed. If none, please type “none”
  • Please list all medications and supplements that you are taking. If you are taking no medications, please type "none". If you would prefer, you can bring a list of yor medications to your exam, please type "Will bring list". (Our associate can make a copy of your list of medication for record)

  • Please answer yes or no if you have any of the following medical conditions:

  • Please answer yes or no if your family members (grandparents, parents, or siblings) have any of the following medical issues:

  • Please sign below to acknowledge that the information given on this form is current:

  • Date Format: MM slash DD slash YYYY

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • I hereby authorize payment of my insurance benefits to SVS Vision, Inc. for expenses incurred on this date for the above-named patient. I further authorize SVS Vision, Inc. to submit claims and supporting information for goods and procedures indicated below and for equivalent goods and procedures according to my insurance carrier’s guidelines. I understand that SVS Vision, Inc. will verify my insurance and obtain any authorizations necessary. I acknowledge that this is not a guarantee of payment by my insurance carrier, and, unless otherwise prohibited, I am responsible for any and all charges not covered by my insurance plan.
  • Date Format: MM slash DD slash YYYY
  • Click Here to Download our Privacy Policy

  • I, (Please enter full legal name above), the “Patient” or “Patient’s legal representative” (if the patient is a minor or an adult who is unable to sign this form) have been presented with the Notice of Privacy Policy (the “Policy” of SVS Vision), and have been offered a copy of such policy to keep for my records.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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