Andrea Sitel 2

Step 1 of 2

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*
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 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

Andrea Sitel 2

Step 1 of 2

HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

MEDICAL DIGITAL VIDEO AND PHOTO CONSENT

PATIENT INFORMATION.

INSURANCE INFORMATION

MEDICAL AND OCULAR HISTORY.

DR MEDINA'S OPTICAL.