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

SVS Vision - Patient Exam Form

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  • 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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