Seeing is Believing
Nacogdoches: 936-569-8278
Patient Information/Geographic Form
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How did you hear about Lehmann Eye Center?
Other:
Date of Last Eye Exam
Examining Doctor
Medical Doctor/City
Preferred Pharmacy/City
PATIENT INFO
Name (First Middle Last)
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Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email Address
Date of Birth
Age
Occupation/Employer
SPOUSE/PARENT INFO
Spouse or Parent's Name
Spouse or Parent's Phone
Spouse or Parent's Birthday
EMERGENCY CONTACT
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Phone
Insurance
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The above information is correct to the best of my knowledge. If applicable, I request that Lehmann Eye Center file Medicare/Insurance Claims and that payments of authorized benefits be made on my behalf to Lehmann EyeCenter/ Doctors Surgery Center for any services furnished to me by the attending physician. I authorize the release of any medical information necessary to process Medicare and any Insurance Claim. I am aware that any balance not covered by my insurancewill be my responsibility.

I authorize Lehmann Eye Center/Doctors Surgery Center to release any information regarding my Medical History, Diagnosis, Care, Treatment, or Progress to the following. We may release all information unless specified to:
(names)
Patient Signature
Date
5300 North Street
Nacogdoches, TX 75965
Phone: 936-569-8278
Fax: 936-569-0275
1-800-753-3846
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