Registration

Kentuckiana’s largest selection of fashion and designer eyewear

Patient Information Sheet

How Did You Hear About Korrect?




Patient Information
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Prescription Information
Family Health History

Please Note any blood family members; parents, grandparents, siblings, children (living or deceased) that have the following conditions:









Patient Health History

Please check if you currently have or have had any of the following:




















Allergies

Please indicate which apply to you:





Medications

Medications may affect your vision. Please list all medications that you are presently taking. If more than 5, provide an additional list at the time of your appointment.

Name of medicine Reason for taking Strength Times per day
Party Responsible for Fees / Vision Insurance
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I hearby authorize KORRECT OPTICAL / SETH J. SUMMERS, OC PSC to furnish information to insurance carriers on my behalf and I hereby assign to the doctor all payment for routine/medical services pertaining to my dependents or myself. I understand that I am responsible for an amount Not covered by my insurance. I understand that I am responsible for any fees or charges for services and/or materials. Payment is requested at time of service. We accept cash, check, CareCreditTM and all major credit cards.

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