• Medical History Questionnaire

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  • MEDICAL / FAMILY HISTORY

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  • Do you currently. or have you ever had any of the following problems

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  • REVIEW OF SYSTEMS

    Please indicate below if you have or ever had problems with the following conditions











  • SOCIAL

  • INSURANCE INFORMATION 

  • a copy of Vision Source Privacy Policy

  • I have read and answered the above questions to the best of my knowledge. I authorize Vision Source to release information as to exam, diagnosis or treatment rendered to me or my child to third party payers and/or health practitioners. I will be responsible for all charges that are not covered or paid by my policy. I am aware that the contact lens fitting and follow-up care may not be covered under the "exam" definition in my policy. I understand that my prescription will be given to vendors in order for Vision Source to be able to process my materials. I further understand that payment is due at the services are rendered unless prior arrangements are made.

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