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Andrea Sitel 2
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2020-05-27T21:40:24+00:00
Andrea Sitel 2
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Name
First
Last
MI:
How do you prefer to be addressed? (nickname, Mr./Mrs., Dr., etc)
Marital Status:
Single
Married
Divorced
Widowed
Sex:
Male
Female
Date of Birth:
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Social Security #
Mailing Address:
Street Address
Apt:
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Illinois
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone:
Work Phone:
Cell Phone:
Texting is ok:
Yes
No
Email:
Emailing is ok:
Yes
No
Note: We do not share your email address or phone numbers
Employment Status (Select one):
Full Time:
Part Time:
Self employed
Retired
Student
Not employed:
Primary Care Physician:
Medical Ins:
Policy #:
Ins Policy holder:
Vision Ins:
Policy #:
Emergency Contact Name:
Phone:
Hobbies:
Main reason for today's visit:
Do you currently wear contact lenses?
Yes
No
If yes, what type of lens do you wear?
Any problems with your current glasses or contacts?
Consent
I agree to the privacy policy.
There are fees to evaluate and update a contact lens prescription. I understand that these fees are not covered
by most insurance, vision, or managed care plans as it is not considered part of a routine eye exam. I will notify
the staff if I decide not to have this service performed.
I understand and agree that health insurance policies are an arrangement between an insurance carrier and
myself. I authorize payment from my insurance carrier direct to this office with the understanding that all
monies will be credited to my account of receipt. However, I clearly understand and agree that all services
rendered are charged directly to me and that I am personally responsible for payment. I also authorize release
of any medical information that may be required in determination of benefits. I have received a copy of Vision
Source's Privacy Statement.
HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient's Signature
*
Date
*
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29
30
31
Year
2024
2023
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
Please print full legal name here.
*
First
Last
(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.
Please initial here
*
I hereby acknowledge that I have been provided with a copy of the Policy.
Please initial here.
*
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 here.
*
Date
MM slash DD slash YYYY
MEDICAL DIGITAL VIDEO AND PHOTO CONSENT
Name
*
First
Last
(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
*
MM slash DD slash YYYY
PATIENT INFORMATION.
Name
First
Last
Exam date
MM slash DD slash YYYY
Sex
Male
Female
Birth date
MM slash DD slash YYYY
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Preferred telephone.
Secondary phone
Employer
Occupation
Referred by:
Email address
*
Signature
*
INSURANCE INFORMATION
Plan name
Group
Insured name.
Relationship to patients
Self
Spuse
Child
Insured ID #
Insured date of birth
MM slash DD slash YYYY
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
Age of sunglasses
Date of last eye exam
MM slash DD slash YYYY
From Doctor
Previous patient?
Yes
No
Do you or any of your blood relatives (I.E. Grandparents, brother or sister) have any of these conditions?
*
Select All
Diabetes
High blood pressure
Thyroid problems
Heart disease
Asthma
Cancer
Glaucoma
Cataracts
Retinal disease
Eye surgery
Eye injury
Other
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.
*
DR MEDINA'S 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
*
Date
MM slash DD slash YYYY
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