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MEDICAL FAMILY HISTORY
(Select Self, Mother, or Father if applicable) |
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Submission applies to acknowledgement of
Contact Lens Care and Policy provided in the office
I, the patient/guardian/responsible party, have accurately and truthfully
completed the information listed on the form. I acknowledge and authorize usage
of my insurance coverage for services provided in the facility. I agree that all
fees incurred are my responsibility regardless of insurance coverage. I
acknowledge that I have reviewed the “Notice of Privacy Practices” regarding the
use and disclosure of my health information. |