Important Note: Please provide your vision and medical insurance cards to the receptionist. if you do not provide us with complete insurance information at the time of your initial vision, we will be unable to bill your insurance company. You are then responsible for payment at the time of service.
Do you have, or are you taking medication to treat the following medical conditions? Please indicate if you have ever had, any of the following medical conditions.
Please note any immediate family members (parents, siblings, children) with the following conditions
I am resonsible for payment for all services and materials provided by Arsulowics Eye Care not covered by an insurer. My signature serves as a "signature on file" for claim processing and for the release of medical information to my insurance carriersI authorize Arsulowicz Eye Care the permission to release my medical records to other health care providers or insurance companies to further enhance my eyecare well-being and for billing procedures.
All EyeCare Services
At Arsulowicz Eye Care , we provide the highest quality eye care to all our patients. Schedule your appointment today.
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