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Located near the corner of Executive Drive and Marcella Road, opposite the Coliseum Crossing Shopping Center.

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Home » Patient Information Form

Becker Eye Care

Welcome to our office!

  • Patient Information

  • Date Format: MM slash DD slash YYYY

  • Responsible Party

    (Only if Patient is a Minor)
  • Date Format: MM slash DD slash YYYY

  • Insurance Information

  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

  • I hereby authorize any necessary treatment by the Optometrist in the practice of Becker Eye Care, LLC and further authorize Becker Eye Care, LLC to file a claim with my insurance(s) providing I have coverage for the services rendered.
    I understand that I am responsible for my bill and any collection fees made necessary to collect payment of services and/or products provided in the event that I do not have the required coverage or the insurance claim is denied, I further authorize the office of Becker Eye Care, LLC to release or obtain any required medical information from my attending physicians or any medical facility.

    Copays are due at the time of service.
  • Date Format: MM slash DD slash YYYY