• Patient Medical History

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  • Are you under medical treatment now?
  • Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
  • Are you taking any medication(s) including non-prescription medicine?
  • Do you use tobacco?
  • Do you use controlled substances?
  • Are you wearing contact lenses?
  • Do you have or have you had any of the following?
  • Are you allergic to to or have you had any reactions to the following?

  • Women only:

  • Are you pregnant or think you may be pregnant?
  • Are you nursing?
  • Are you taking oral contraceptives?

  • Financial Arrangements

    For your convenience, we offer the following methods of payment. Please check the option you prefer. payment in full at each appointment. 

     

  • Late Charges

    If I do not pay the entire new balance within 25 days of the mothly billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed each month (if allowed by law). I realize that failure to  keep this account current may result in you being unable to provide additional services except for emergencies or where there is prepaymemt for additional services. In the case of default on payment  of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding accouint balances. 

     

  • Authorizatin and Release

    I certify that I have read and understand the above information tro the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information including the diagnosis and the records of any treatment or examination rendered to me ot my child during the period of such health care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the doctor or medical group insurance benefits otherwise payable to me. I understand that my health insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. 

  • Should be Empty: