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Across from Chase Bank on Main Street in Oak Hill, WV

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Home » Patient Health History

Patient Health History

  • Contact Lens History

  • Current Glasses Information

  • AllergyOnset DateReactionSeverity 
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  • Please list all prescriptions, over the counter and herbal medications
    DateNameStrengthDirections 
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  • Please list all medical alerts
    (i.e., Do Not Dilate, epilepsy, DNR / DNI)
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  • Do you take medications for any of these conditions?

  • Social History

  • DateEyeProcedureSurgeonComplications 
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  • Southern Eye Care Financial Policy


    We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies.

    1. Professional fees are due when services are rendered. A deposit of 50% is required towards the total cost of glasses or contacts before an order can be placed. The balance is due in full at the time of dispensing. We accept personal checks, cash, Discover, Visa MasterCard and CareCredit.

    2. When glasses or contacts are purchased through VSP or any other insurance, the balance is due in full when the order is placed.

    3. Keep in mind that your insurance policy is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign the benefits to the doctor.

    4. If your insurance company does not pay the practice within 45 days, you are responsible for all fees due.

    5. If you are insured by a plan that we do not accept, we will prepare and send the claim for you on an unassigned basis. Therefore, our charges for your care are due at the time of service.

    6. Not all-insurance plans cover all services. In the event your insurance plan determines a service to be “not covered,” you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

    I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.
  • (or responsible party, if minor)

  • Payments can be made through CareCredit at no interest for 6 months.
    www.carecredit.com or call 1-800-365-8295 to apply.