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Dry Eye
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Scleral Lenses
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Myopia Management
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Ophthalmology
We are located next to Liberty Toyota Burlington
Call 609-910-5543
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Home » Contact Us » Patient History Form

Patient History Form

Patient History Form

  • Insurance Information

  • MM slash DD slash YYYY
  • I authorized and consent to the examination and treatment of the above patient. I certify that the information above is correct. I authorize the doctor to release any information needed to process my insurance claims and I assign payment to the provider of any benefits. I am responsible for any copays at the time of the visit and I will forward payment for any expenses applied to my deductible once my insurance company is billed. Full payment is due for out of pocket contact / glasses expenses before they can be ordered.
  • MM slash DD slash YYYY
  • * Patient records only maintained for six years after the visit.