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Arman Penilla
2021-06-22T18:04:29+00:00
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PATIENT INSTRUCTIONS FOR YOUR APPOINTMENT
You are scheduled for an appointment for a comprehensive eye exam and we would like to thank you for letting us provide your eye health and vision care needs. In order to give you the best care possible and provide the most beneficial use of your time with us, please read the following and bring the requested items to your appointment. Our doctors want to give you the most thorough care possible so please note that our eye exams take approximately 1 hour.
Due to COVID-19, we have made some adjustments to our appointment procedure.
NEW PATIENTS:
Please email copies of your Medical Insurance Card as well as provide any Vision insurance information. We need this information prior to your exam date to preverify your benefits.
Please fill out and submit your Online Patient Registration and Medical History Forms. These can be found on our website www.rockawaybeachoptometry.com. Click on the OUR SERVICES tab and choose PATIENT FORMS
CURRENT PATIENTS:
If you have new insurance, please email copies of your Medical Insurance Card as well as provide any Vision insurance information. We need this information prior to your exam date to preverify your benefits. Please notify our staff if your address, phone number or email has changed
Please email or bring a copy of a list of all medications that you currently use. (prescription and nonprescription)
ALL PATIENTS
Please wear or bring your prescription eyeglasses to your appointment. If you are a contact lens wearer please wear your contact lenses to the appointment and bring your eyeglasses. If you are new to our office, please bring a copy of your current contact lens prescription or any packaging that contains the prescription information
Please do not bring a companion with you to your appointment. The only exceptions are a parent or caregiver.
Check-in:
Please text or call our office from your car when you arrive. All check-in will be done by phone. We will let you know when you may enter the office.
We require a mask or face covering for all patients and their companions
Temperatures will be taken for all patients and caregivers.
PUPIL DILATION
In addition to testing your vision, the doctors will be assessing the overall health of your eyes as part of your exam. For health safety concerns due to COVID-19 we are trying to minimize the use of eyedrops and keep direct contact to a minimum. Our doctors will be utilizing Digital Retinal Imaging Technology to examine and assess the health of your eyes rather than dilation eyedrops as much as possible. Our staff will inform you of any out of pocket costs for this testing with your insurance.
If you need to cancel or reschedule your appointment please call (650) 738-2205 or email customerservice@rockawaybeachoptometry.com 24 hours before your appointment. There is a $50 cancellation or no show fee for less than 24 hours notice.
Our office is located at 769 Hickey Blvd, Pacifica, CA 94044 in the Fairmont Shopping Center at Hickey Blvd and Skyline Blvd.
Thank you for choosing our office for your eyecare – we look forward to seeing you!
How did you hear about us?
Name (Last, First, Middle)
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Address Line 2
Preferred Language
Race
Communication Preference
Ethnicity
Phone
*
Date of Birth
*
MM slash DD slash YYYY
Sex
*
M
F
Last 4 of Social Security #
*
Email
*
Employment Status
Employer
Occupation
Marital Status:
Last Eye Exam Date
MM slash DD slash YYYY
Reason for visit:
*
If you wear glasses, then when specifically?
*
Always
Only while driving
For reading
Sunglasses
Computer
I don't wear glasses
If you wear contact lenses, then what type?
*
Disposable soft
Regular soft
Gas permeable
I don't wear contact lenses
If no, are you interested in contact lenses?
Yes
No
If you've ever had eye surgery, list the date and type
*
How many hours per day do you use a computer?
*
0-2
2-4
4-6
6-8
8+
Insurance Information
Medical Insurance: Primary
*
Member's Name
*
Date of Birth
*
MM slash DD slash YYYY
ID#
*
Secondary (If no seconday, type none)
*
Member's Name (If no secondary, type none)
*
Date of Birth (If no secondary, type none)
ID# (If no secondary, type none)
*
Vision Insurance: Primary
*
Member's Name
*
Date of Birth
*
MM slash DD slash YYYY
ID#
*
Secondary (If no secondary, type none)
*
Member's Name (If no secondary, type none)
*
Date of Birth (If no secondary, type none)
ID# (If no secondary, type none)
*
In case of emergency please contact:
Relationship to Patient
Phone
Referred by:
Financial Responsibility
I permit a copy of this authorization to be used in place of the original, and request payment of insurance benefits to ROCKAWAY BEACH OPTOMETRY. I understand and accept financial responisibility for all and any service rendered to me. I understand my insurance company is billed as a courtesy to me and payment of any bill is my responsibility. PARENT OR GUARDIAN SIGNATURE:
*
Date
*
MM slash DD slash YYYY
Notice of Privacy Practices:
A "Notice of Privacy Practices" that describes how my protected health information is used and disclosed has been made available to me. I understand I may request a printed copy at any time. PATIENT INITIALS:
*
Date
*
MM slash DD slash YYYY
Confidential Medical History & Review of Symptoms
Family History
Please answer the questions below regarding your immediate family (parents, grandparents, siblings, children)
Family History
Please answer the questions below regarding your immediate family (parents, grandparents, siblings, children)
Blindness/Vision Loss
*
Yes
No
If yes, which family member?
Crossed or "Lazy" eyes
*
Yes
No
If yes, which family member?
Cataracts
*
Yes
No
If yes, which family member?
Glaucoma
*
Yes
No
If yes, which family member?
Macular Degeneration
*
Yes
No
If yes, which family member?
Retinal Detachment
*
Yes
No
If yes, which family member?
Diabetes
*
Yes
No
If yes, which family member?
High blood pressure
*
Yes
No
If yes, which family member?
Heart disease
*
Yes
No
If yes, which family member?
Thyroid disease
*
Yes
No
If yes, which family member?
Cancer
*
Yes
No
If yes, which family member?
Lupus
*
Yes
No
If yes, which family member?
Other eye disease
*
Yes
No
If yes, which family member?
Do YOU currently have any problems in the following areas:
Blindness
*
Yes
No
Blurred Vision
*
Yes
No
Crossed or "lazy" eyes
*
Yes
No
Cataracts
*
Yes
No
Glaucoma
*
Yes
No
Macular degeneration
*
Yes
No
Retinal detachment
*
Yes
No
Eye trauma or injury
*
Yes
No
What type of injury/trauma and when?
*
Distorted vision/halos
*
Yes
No
Loss of side vision
*
Yes
No
Double vision
*
Yes
No
Dryness
*
Yes
No
Mucus discharge
*
Yes
No
Redness
*
Yes
No
Sandy or gritty feeling
*
Yes
No
Itching
*
Yes
No
Burning
*
Yes
No
Glare/light sensitivity
*
Yes
No
Eye pain or soreness
*
Yes
No
Flashes
*
Yes
No
Floaters
*
Yes
No
Fever/weight changes
*
Yes
No
Rosacea
*
Yes
No
Allergies/hayfever
*
Yes
No
Sinus congestion
*
Yes
No
Dry throat/mouth
*
Yes
No
Asthma
*
Yes
No
Emphysema
*
Yes
No
Chronic bronchitis
*
Yes
No
Diabetes
*
Yes
No
Vascular disease
*
Yes
No
High cholesterol
*
Yes
No
High blood pressure
*
Yes
No
Chronic diarrhea
*
Yes
No
Kidney/bladder
*
Yes
No
Rheumatoid arthritis
*
Yes
No
Anemia
*
Yes
No
Bleeding problems
*
Yes
No
Thyroid
*
Yes
No
Depression
*
Yes
No
Headaches (chronic)
*
Yes
No
Migraines
*
Yes
No
Seizures
*
Yes
No
List any medication allergies
*
List any medications you're taking
*
Signature
*
Date
*
MM slash DD slash YYYY
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