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Patient Info Sheet

  • Visual Information

  • Lifestyle Factors

  • (eye strain/tilt your head)
  • Contact Lens Rating

  • 1 being poor, 5 being excellent
  • 1 being poor, 5 being excellent
  • Health Information

  • Do you or anyone in your family have a history of:
    (please check all that apply)
  • (please check all that apply)
  • MedicationDosage 

  • NOTE: Your insurance plan is a contract between you and your insurance company. Our office cannot be responsible for determining your benefits. You must notify us if your insurance plan covers routine vision prior to any services. If you are not sure if your plan covers routine vision, payment is due at the time services are rendered. If your plan requires a referral, it is your responsibility to obtain one from your primary care doctor prior to your appointment. If your insurance denies the charges incurred, they are your responsibility.

    Assignment of Benefits: I hereby consent to such treatment and patient care, which may be considered necessary or advisable as a patient of Adriana Palumbo, OD for services rendered. I understand that I am ultimately responsible for all charges on services rendered, whether or not paid by insurance.

  • MM slash DD slash YYYY
  • In case of divorced or separated parents, our policy is that the parent bringing the child into our office is responsible for payment of all fees.