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| * Change in vision insurance? |
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| If yes, type of vision insurance: |
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| * Please list allergies to Medications: |
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| * List all medications you take: |
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| * Are you pregnant and/or nursing: |
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| * Please list current medical conditions: |
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| * Please state any problems you are presently having with your vision |
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| Assignment & Release
I, the undersigned, certify that I (or my dependent) have insurance coverage
with |
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| and assign directly to EyeCare Professionals, P.C., all changes
whether or not paid by insurance. I herby authorize the doctor to release all information necessary to secure
the payment of benefits. I authorize the use of the signature on all insurance submissions. |
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| * Responsible party signature: |
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