WARNING

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

Close [x]
9302 N. Meridian Street, Suite 170 Indianapolis, IN 46260
317-818-0541
m

Adult Patient History Questionnaire

EYE HEALTH INFORMATION

MEDICAL INFORMATION

The undersigned agrees that all past due amounts shall be charged $10.00 peer month on the unpaid balance commencing thirty (30) days after billing. The undersigned assumes and agrees to pay all collection agency fees paid by us, attorney fees, court costs, and other cost incurred while collecting the amount due.

The under signed give permission to and exchange information to those professionals that they are being referred to or to those professionals that referred them to our office. The undersigned gives permission to exchange information with their insurance company when necessary.

Eyes For Wellness * 9302 N Meridian St, Suite 170 * Indianaoplis, IN 46260 * 317-818-0541 * 317-818-1756 fax * www.eyes4wellness.com *