Have you ever worn glasses?

Do you wear glasses now ?

Reason for visit

Do you take any medications

Please check if you take any of the following:

Do you have any allergies?

Please check if you or a family member have ever had any of the following conditions:

Diabetes

Heart Disease

Thyroid Problems

HIV or AIDS

Cataracts

High Blood Pressure

Seasonal Allergies

Arthritis

Glaucoma

Are you currently Pregnant

Are you currently brest-feeding

Do you wear contact lenses currently

Have you ever worn contact lenses

Eye Surgery or Trauma

I CERTIFY THAT I HAVE INSURANCE COVERAGE WITH

SPEXX EYECARE MAY USE MY 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 TREATMENT PLAN IS COMPLETED OR ONE YEAR FROM THE DATE SIGNED BELOW.

Medicare/Medigap Authorization:
I request that payment of authorized Medicare benefits and, if applicable, Medigap benefits, be made to me or on my behalf to Spexx Eyecare for any services furnished to me by this provider.
To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services, my Medigap insurer, and their agents any information needed to determine these benefits or benefits for related services.