Patient Demographics & Medical History

Patient Information

Please type your last name.

Name as on insurance card

Please enter your first name

Name as on insurance card

Please enter your middle initial

Please type your last name.

Please enter your street address

Please enter your city

Please use only 2 character state letter code

Please enter your zip code

Please enter your primary / cell phone number

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Please enter a valid email address.

Please provide your email address to receive appointment reminders and other important information. Your privacy is a primary concern and email addresses will not be shared.

Please specify your sex

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Please select your marital status

Please enter your spouse's name

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Primary Insurance

Policy Holder’s Information
Please enter the policy holder's name

Name as on insurance card

Please enter the relationship to patient

Please enter your insurance company's name

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Please enter the policy holder's address

Secondary Insurance

Policy Holder’s Information
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Assignment and Release

I certify that I, and/or my dependent(s) have insurance coverage with above insurance and assign directly to LFVC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
LFVC may use my healthcare information and may disclose such information to the above named insurance company(ies) and their agents for this purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Please type your full, legal name in the signature box to submit your legally binding digital signature

* Please type your full, legal name in the signature box to submit your legally binding digital signature

Please enter the signing party's relationship to the patient

In Case of Emergency, Contact

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Please provide the above information to help our doctors give the best eye care possible. Some ethnicities are prone to certain illnesses, and this information will help in prevention and treatment.

Billing Agreement

Payment including but not limited to co-pays and deductibles are due in full at time of service. Return checks are subject to a $30 return check fee.
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* Please type your full, legal name in the signature box to submit your legally binding digital signature

Medical History

Please type your last name.

Name as on insurance card

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Review of Systems

Please check any areas that you currently or have ever had problems out of the ordinary

Eyes

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Skin

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Ears, Nose, Mouth, Throat

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Respiratory

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Vascular/cardiovascular

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Review of Systems (continued)

Please check any areas that you currently or have ever had problems out of the ordinary

Neurological

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Bones/joints

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Endocrine

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Genitourinary

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Psychiatric

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Lymphatic/Hematologic

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Constitutional

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Immune System

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Cancer

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Family History

Please note any family history of the following ailments and list the relationship to you (living and deceased)

Please answer the required question

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