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Additional Notes

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Please Enter Your Medical/Vision Insurance Information

Medical insurances typically outsource vision to a group such as VSP, Eyemed, Spectera, Superior, etc.

Enter your vision insurance if any

Medical History


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Certification and Assignment


To the best of my knowledge, the above information is complete and correct. I understand that it's my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise pays to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of signature on all insurance submissions.

The above named doctor may use any health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.



COVID-19

Please read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.

I do not currently have, nor have I had in the last two weeks, a fever, cough, shortness of breath, sore throat, loss of smell/taste or other cold symptoms.
To the best of my knowledge, I do not have,nor have I been in direct contact with someone who has confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last thirty (30) days.
Neither I, nor anyone living in my immediate household, have travelled outside of the United States in the last 30 days.

I have read the above and have answered the health questions above honestly and to the best of my knowledge. I understand that doctors and team members are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate potential exposure by one hundred percent.

By signing this form below, I agree that I will not hold  any of its doctors or team members personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge

P and fts doctors and team members for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.



Review and Submit

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  • 1. Personal Details
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  • 2. Appointment details
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