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  • 4
    Please provide us with a current email address. (We may contact you regarding appointments and office information.)
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  • 6
    Is there another number where you can be contacted?
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  • 7
    We use this for checking insurance benefits
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    Please provide a number for us to call in case of an emergency.
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  • 11
    Emergency contact relationship to the patient
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    Please select all that apply to help us to customize your care.
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  • 15
    Let us know how you found us.
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    Please tell us their name or care facility
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  • 23
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  • 24
    Family Tree Optometric has decided to OPT-OUT of the Medicare program including all beneficiaries and services. A Medicare private contract will require signatures in office in order to receive care. You CAN NOT sign this contract if you are seeking emergency or urgent care; you may be asked to seek care elsewhere if this is determined to be the case.
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    For checking insurance coverage
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    For checking insurance benefits
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  • 55
    * This information is strictly confidential, if you prefer, you can discuss this with your doctor in private.
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  • 56
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  • 59
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  • 60
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  • 61
    Select all that apply
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  • 62
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  • 63
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  • 64
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  • 65
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  • 66
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  • 67
    Cardiovascular
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  • 68
    Cardiovascular
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  • 69
    Cardiovascular
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  • 70
    Constitutional
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  • 71
    Constitutional
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  • 72
    Endocrine/Glands
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  • 73
    Endocrine/Glands
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  • 74
    Gastrointestinal
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  • 75
    Gastrointestinal
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  • 76
    Genitourinary
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  • 77
    Ear/Nose/Mouth/Throat (Head)
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  • 78
    Ear/Nose/Mouth/Throat (Head)
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  • 79
    Ear/Nose/Mouth/Throat (Head)
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  • 80
    Ear/Nose/Mouth/Throat (Head)
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  • 81
    Ear/Nose/Mouth/Throat (Head)
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  • 82
    Hematologic/Lymphatic
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  • 83
    Hematologic/Lymphatic
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  • 84
    Immunologic
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  • 85
    Intergumentary (Skin)
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  • 86
    Bones/Joints/Muscles (Musculoskeletal)
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  • 87
    Bones/Joints/Muscles (Musculoskeletal)
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  • 88
    Bones/Joints/Muscles (Musculoskeletal)
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  • 89
    Neurological
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  • 90
    Neurological
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  • 91
    Neurological
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  • 92
    Psychiatric
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  • 93
    Respiratory
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    Respiratory
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  • 95
    Respiratory
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  • 96
    Patient's weight
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  • 97
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  • 98
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  • 99
    You agree that this information is true to the best of your knowledge
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  • 101
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