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12750 Bass Lake Rd. Maple Grove, MN 55369 Phone: 7635531811 Fax: 7635530131Health History Form11/12www.basslakefamilyeyecare.impersonal Information: Name: Preferred Name: Gender: Married Single Male
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Start by gathering all necessary forms and documents, such as identification and insurance cards.
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Fill out the patient information section, providing details like name, date of birth, and contact information.
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Provide your medical history, including any previous eye conditions, surgeries, or medications being taken.
04
Fill out the insurance information section, including your policy number and any primary or secondary coverage.
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Specify the reason for your visit or any specific concerns you have about your eye health.
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If applicable, provide information about your primary care physician and any referrals you may have received.
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Review the completed form for accuracy and completeness before submitting it to Bass Lake Family Eye.
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Anyone in need of eye care services can benefit from Bass Lake Family Eye. This includes individuals of all ages, from children to seniors. Whether you have a routine eye exam, need a new prescription for glasses or contact lenses, or require treatment for an eye condition or injury, Bass Lake Family Eye can provide the necessary care. They also offer specialized services like pediatric eye care, vision therapy, and sports vision care.
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Bass Lake Family Eye is a family-owned eye care center that provides comprehensive eye care services.
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The owners or operators of Bass Lake Family Eye are required to file the necessary paperwork.
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