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4092 Danada Vision Center LLC
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2020-01-20T19:09:00+00:00
4092 Danada Vision Center LLC
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Work Phone:
Home Phone:
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Vision Insurance:
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Subscriber Name:
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Subscriber ID:
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Subscriber DOB:
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MM slash DD slash YYYY
Secondary Vision Insurance:
Subscriber ID:
Medical Insurance:
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Subscriber Name:
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Subscriber DOB
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Subscriber ID:
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Email
Reason for Visit - Check all that apply
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Routine Exam
Contacts
Eye Infection/ Injury
Eye Lash Treatment
Glasses
Sunglasses
Dry Eye Treatment
Lasik Consult
Las Eye Exam:
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1 Year
2 Years
3+ Years
Have you had eye surgery? If yes please explain:
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Do you wear glasses?
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No
All the time
Sometimes
While Driving
While Reading
EYE HISTORY - Do you Have or have you ever had a problem in the following areas:
Cataracts
Macula Disease
Glaucoma
Dry Eye
Eye Infection
Flashes/ Floaters
Retinal Defects
Eye Injury
Iritis/ Uveitis
Redness
Eye Burning
Itching
Tearing
Watering
Eye Discharge
Blurred Vision
Eye Strain
Eye Pain
Light Sensitivity
Headaches
Poor Night Vision
Lazy Eye
Double Vision
Loss of Vision
FAMILY HISTORY- Ocular:
Macular Degeneration
Blindness/ Vision Impairment
Cataracts
Glaucoma
Please list relationship to person(s) with listed conditions:
FAMILY HISTORY- Medical:
Cancer
Diabetes Type 1
Diabetes Type 2
High Blood Pressure
Thyroid Disease
Heart Disease
Please list relationship to person(s) with listed conditions:
Do you have or have you ever had any history of - CONSTITUTIONAL:
Cancer
Developmental Disability
Fever
Weight loss/gain
EAR, NOSE, MOUTH AND THROAT:
Hearing Loss
Dry Mouth
Sinus Congestion
Post Nasal Drip
Chronic Cough
NEUROLOGICAL:
Multiple Sclerosis
Epilepsy
Tumor
Stroke
Headaches/ Migraines
Autism
PSYCHIATRIC:
Anxiety/ Depression
Bipolar/ Schizophrenia
Attention Deficit
CARDIOVASCULAR/ VASCULAR:
High Blood Pressure
High Cholesterol
Vascular Disease
Congestive Heart Failure
Heart Disease
RESPIRATORY:
Smoke/ Tobacco Products
Asthma
Chronic Bronchitis
Emphysema
Snoring/ Sleep Apnea
GASTROINTESTINAL:
Crohns Disease
Colitis
Ulcer
Acid Reflux
Celiac Disease
GENITOURINARY:
Kidney/ Bladder Problems
STD
If yes to STD question please list:
Bones/ Joints/ Muscles
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Muscle/ Joint Pain
Rheumatoid Arthritis
INTEGUMENTARY:
Eczema:
Rosacea
Psoriasis
Shingles/ Herpes
ENDO:
Diabetes Type 1
Diabetes Type 2
Thyroid Dysfunction
Hormonal Dysfunction
HEM/ LYMPH:
Anemia
Ulcer
Hypercholesteremia
ALLERGY:
Seasonal/ Environmental
Sjrogens Syndrome
Other:
If other please list:
Please note any additional health history not listed:
HIPAA ACKNOWLEDGMENT:
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Your signature acknowledges that you have read a copy or been given the opportunity to read Danada Vision Center Notice of Privacy Practices. Federal regulations (Health Insurance Portability and Accountability Act - HIPAA) Require we ask for your signature of receipt.
Name
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Last
CONSENT FOR TREATMENT AND FINANCIAL POLICY:
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By signing this form I consent to treatment for myself and/ or on behalf of the minor for which this information pertains. I giver permission for the Doctor(s) to examine, diagnose and initiate treatment as deemed appropriate.I further, attest that I am the parent or legal guardian of the Minor and have the authority to authorize care and treatment. I agree to be responsible for all services rendered on my behalf or my dependents. I understand I am responsible for any and all fees my insurance does not cover. I understand that payment is due at the time of service unless other arrangements are made. I have read and agreed to Danada Vision Center's Financial Policy. Please understand, since an order for glasses is a custom prescription designed for each individual patient, once it is in progress, we will be unable to cancel the order.
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Relationship to patient:
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