Patient Information Form

Please print/Por favor completar:



Date/Fecha SSN: DOB/Fecha de Nacimiento

Last Name Name / Apellidos Nombres

Address/Direccion: City/Ciudad:

State/Estado: Zip Code/Codigo Postal: Phone Number/Telf:

Email:

Sex/o: Status/Edo. Social: Race/Raza:
Language/Idioma:



RELEASE OF FINANCIAL RESPONSIBILITY/ CONSENTIMIENTO FINANCIERO

of all insurance benefits otherwise payable to me for the services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Autorizo directamente el pago al Dr. de todos los beneficios ortogados por mi seguro. Entiendo que soy responsable de todos los cobros, pagados o no por mi seguro, y por todos los servicios recibidos por mi o mis dependientes. Autorizo al Dr. ya mencionado y/o acualquier proveedor de servicios en esta oficina de suministrar cualquier informacion requerida para asegurar el pago de mis beneficios. Autorizo el uso de mi firma para todo documento relacionado con mi seguro.


Signature of responsible party/ Firma del responsable: ___________________________ Date/Fecha: _______________________



Review of Systems:
Please indicate below your history of or current medical problems in the check box if a YES. If you have never had a problem leave blank.
Por favor indique su historial medico en las cajitas de abajo, marcando si tiene o ha tenido ese problema.


CONSTINTUIONAL






GENITOURINARY




HEAD, EYES, EARS, NOSE & THROAT





METABOLIC ENDOCRINE


RESPIRATORY





NEUROLOGICAL




PSYCHIATRIC



CARDIOVASCULAR





SKIN


GASTROINTESTINAL







MUSCULOSKELETAL


HEMATOLOGIC/LYMPHATIC


IMMUNOLOGIC






Other:


The mission of South Florida Laser Eye Center is to safeguard, preserve, and improve the vision of our patients. We have a patient centric approach to deliver exceptional eye care which is rooted in the personalized care, support and understanding we provide each patient.

We offer a full range of eye care services including cataract surgery, glaucoma treatment, medical and surgical retina and vitreous services including diabetes and macular degeneration, LASIK, corneal transplants, neuro ophthalmology, comprehensive eye exams, contact lens examinations including specialty lenses and fits, and a full service optical department.

Founded in 1994 by Dr. Hassan Tavakkoli, South Florida Laser Eye Center has helped thousands of patients see the world more clearly. We are dedicated to improving quality of life through sharper vision.
Location
8051 W Sunrise Blvd, Plantation, FL 33322, United States
  • (954) 474-2900
  • Medical Skype Name
Mon
08:00 am - 5:00 pm
Tue
08:00 am - 5:00 pm
Wed
08:00 am - 5:00 pm
Thu
08:00 am - 5:00 pm
Fri
08:00 am - 5:00 pm
Sat
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Sun
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