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WELOCOME TO OFFICE

Welcome To Our Office

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Patient"s Name
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Address
PLease Select
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Relation to Patient
Features include: · Request Appointments Online · Confirm Appointments via Email · Receive Text Message Appointment Reminders · Submit Patient Satisfaction Surveys · Refer Your Friends Online
Communication Preference:
I authorize payment of my benefits directly to Advanced Eye Care Center for services rendered. I also authorize release of any medical information that may be required in determination of such benefits. I understand that some services and procedures may not be covered by my insurance carrier. Fees not paid by my insurance carrier will be my responsibility. This authorization is in effect until I choose to revoke it.
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