Please Note any blood family members; parents, grandparents, siblings, children (living or deceased) that have the following conditions:
Please check if you currently have or have had any of the following:
Please indicate which apply to you:
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.
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.