Patient History Form

Our Doctors and staff will strive for persistence of these standards on a daily basis, for they are the core elements of Clarity Eyecare..

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. I certify that I, and/or my dependant(s), have insurance coverage with

and assign directly to Clarity Eyecare, PLLC., 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 have read your consent policy and agree to its terms. I authorize the release of any medical information necessary to process insurance claims and request payment of benefits either to myself or the party who accepts assignment / participates.

***If Patient is under the age of 18*** As the party responsible for medical decisions for the child represented in this document, I hereby give my consent to Clarity Eyecare, PLLC to render both emergency and non-emergency healthcare services both in and out of my physical presence.