Skip to content
Search for:
admin
2020-05-27T21:18:49+00:00
Valeria Training Form
Step 1 of 3
33%
Exam Date
Date Format: MM slash DD slash YYYY
Name
Last
First
Sex
Male
Female
Brith Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Select your preferred option
Home
Work
Cell
Preferred Telephone Number
We use phone calls to remind patients for their appointments. We will use the phone number you provide and the call may be live or prerecorded.
Select your preferred option
Home
Work
Cell
Secondary telephone number
Secondary Telephone Number
Employer
Occupation
Referred by
Email
Signature
Insurance Information
Plan Name
Group
Insured name
First
Last
Relationship to patient
Self
Spouse
Child
Check one
Insured ID
Insured Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Medical and Ocular History
What is the reason for today's exam?
Are you planning to get new glasses today?
Yes
No
Are you planning to get new contact lenses today?
Yes
No
Age of present glasses
Date of sunglasses
Date of last exam
Date Format: MM slash DD slash YYYY
From Doctor
First
Last
First time
Yes
No
Diabetes
Self
Relative
None
High blood pressure
Self
Relative
None
Thyroid problems
Self
Relative
None
Heart disease
Self
Relative
None
Asthma
Self
Relative
None
Cancer
Self
Relative
None
Glaucoma
Self
Relative
None
Cataracts
Self
Relative
None
Retinal disease
Self
Relative
None
Eye surgery
Self
Relative
None
Eye injury
Self
Relative
None
Other
Self
Relative
None
Do you see double?
Yes
No
Frequent headaches
Yes
No
Are you pregnant?
Yes
No
Eyes been dilated?
Yes
No
Year
Primary care Dr.
Please explain any positive findings
Are you taking any eyedrops? (Prescription or over the counter) Please list:
Are you taking any other medications? (Prescription or over the counter) Please list:
Do you have any allergies, medication or other? If yes, please explain.
HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, (the "Patient" or "Patient's legal representative"), have been presented with the Notice of Privacy Policy of Dr. Ariel Medina, and have been offered a copy of such policy to keep for my records.
I hereby acknowledge that I have been provided with a copy of the Policy.
I hereby refuse to acknowledge receipt of the Policy. I understand that even though I may refuse to sign this acknowledgment, Provider may still provide treatment to me.
Signature of patient
I, (the "Patient" or "Patient's legal representative") understand that photographs, videotapes, digital, or other images may be recorded to document my care, and I consent to this. I understand that Dr. Ariel Medina will retain the ownership rights to these photographs, videotapes, digital, or other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner that will protect my privacy and that they will be kept for the time period required by law. Images that identify me will be released and/or used outside the institution only upon written authorization from me or my legal representative.
Signature of patient
Date
Date Format: MM slash DD slash YYYY
Dr. Medina Optical
FRAMES
Most frames are warranted against manufacture defects in workmanship for a period of one year from the date of the purchase. Frames are not covered for breakage or loss. In the event that a frame exchange is required for patient satisfaction, a one-time exchange up to the original purchase price of the frame may be made within the first 7 days of purchase. Fees may apply. The Optical is not responsible for Patient's own frames.
PRESCRIPTION LENSES
We guarantee that your lenses will be made and inspected to the specification of the prescription given.
COATINGS
Anti-Reflective coating and scratch coating are warranted at no cost to you for a period of one or two years from the date of the purchase. This warranty does not cover loss, theft, or hairline scratches which have not effect on vision. Dispensing fees will apply with replacement of lenses.
NON-ADAPT POLICY
Lenses are custom made for you, they are non-refundable. It is our policy to remake your lenses one time only at no cost to you if the original prescription is in error or if the patient is non-adapt to a progressive lens. For non-adapt progressive lenses, we will make new lenses in any other design that you wish at no charge within 90 days of dispensing. Original lenses are a custom prescription item which must be discarded. No refunds are issued if the difference in cost or the remake pair is of lesser value. Our lens treatments are the most durable surface protection available. However, any lens can scratch or break. Please follow recommended procedures for care and cleaning.
CANCELLATION POLICY
Patient has 24 hours to cancel the order. See sales associate for details.
OUTSIDE DOCTOR'S CHANGE
One Doctor's change will be honored for a period of 30 days from the date of dispense. Costs associated other than prescription will be responsibility of the patient.
Patient's signature
Print Name
First
Last
Date
Date Format: MM slash DD slash YYYY
Go to Top