Patient Form

Patient Form

Acknowledgement Form

List of those who have my permission to access to my medical information
Patient Information

Primary Insurance

Secondary Insurance

Emergency Contact

Authorization For Treatment and Financial Agreement

I authorize treatment of the person named as patient and agree to pay for all services rendered to patient including but not limited to any amounts not paid by my insurance company. I will be responsible for all copayments ,deductibles,coinsurance,refraction fees and/or non-covered services. I request payment of authorized benefits.

All deliquient account will be charged an interest rate of 1.5% per month (18% per annum). In the event any balance is not paid as agreed, the undersigned agrees to pay all collection fees. In the event of a lawsuit to collect the unpaid balance ,the undersigned further agrees to pay court costs and reasonable attorney fees. You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by sending text message or e-mails, using any email address you provide to us. Method of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable
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By signing below you verify that the information listed is correct and up-to-date

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