If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Follow Us

New Patient Health History Form

We require 2 separate phone numbers

Privacy Practices

I authorize Eye1st Vision Center to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Eye1st Vision Center insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I am the guarantor of this account, and I have read, understand, and agree to these office policies. Further, I acknowledge that I am familiar Eye 1st Vision Center Privacy Practices. (To view Eye 1st Vision Center Privacy Practices - Click on link below)

(By entering your name here, you are digitally signing this form and stating that all of the information is true to the best of your knowledge)

View Eye 1st Vision Center Privacy Practices.