Patient information

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Billing information

Primary Vision Insurance



Primary Medical Insurance

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Eye History

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Contact Lens Wearers Only


Family Eye History

Does anyone in your family have any of these eye conditions?





Medical History:

Do you have any of these medical conditions?

Family Medical History

Does anyone in your family have any of these medical conditions?

Review Of Systems

Social History

Policies, Consent, Submit Data


AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION

to release health information identifying me [including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services] under the following terms and conditions:



To whom may the information to be released:
Vision Source Magnolia
18000 FM 1488 Suite 100
Magnolia, TX 77354

We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you can revoke it later.

I have read and understand this form. I am signing it voluntarily. I authorize the disclosure of my health information as described in this form.



If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:



HIPAA ACKNOWLEDGEMENT FORM

View Notice of Privacy Practices Form



Financial Policy

View Financial Policy Form



Contact Lens Policy

View Contact Lens Form