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Dr. Medina’s Optical – Robert Training Form #2Robert Avila2021-03-19T19:06:11+00:00

Dr. Medina's Optical - Robert Training Form #2

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  • Date Format: MM slash DD slash YYYY

  • PATIENT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • WE USE PHONE CALLS TO REMIND PATIENTS OF THEIR APPOINTMENTS. WE WILL USE THE PHONE NUMBER YOU PROVIDE AND THE CALL MAY BE LIVE OR PRERECORDED.

  • INSURANCE INFORMATION

  • Date Format: MM slash DD slash YYYY

  • MEDICAL AND OCULAR HISTORY

  • Date Format: MM slash DD slash YYYY

  • DO YOU OR ANY OF YOUR BLOOD RELATIVES (I.E. GRANDPARENTS, PARENTS, BROTHER, OR SISTER) HAVE ANY OF THESE CONDITIONS?

  • PROCEED TO CONSULTATIVE Rx FORM

  • 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 scratched 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 that 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 dispense. Costs associated other than prescription will be responsibility of the patient.

  • Date Format: MM slash DD slash YYYY

  • HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OR PRIVACY PRACTICES

  • [Please print full legal name here]
  • [Please initial here]
  • [Please initial here]
  • Date Format: MM slash DD slash YYYY

  • MEDICAL DIGITAL VIDEO AND PHOTO CONSENT

  • 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.

  • [Please print full legal name here]
  • Date Format: MM slash DD slash YYYY
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