Patient History Form

Please Read:

In order to control the cost of billing, we ask that the patient's portion is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge on all returned checks. Payment from my insurance is to be paid directly to Ultimate Eyecare Santa Fe, LLC. I understand that Medicare Novitas-Part B will be billed as my primary insurance. I underetand that billing antsecondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.

Health History

Current Eye Symptoms

Spectacle Lens History

Contact Lens History

Please rate the following on a scale of 1-10, with 1 being POOR to 10 being EXELLENCE