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Marciano Family OptometricBerenice2022-06-20T17:22:07+00:00

Marciano Family- West Palm

Patient Name
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Address
Gender
Marital Status
Ethnicity
Preferred Language
Preferred Contact Method
Race
Insurance Information
Medical Insurance
ID Number
Subscriber Name/DOB
 
Insurance Information
Vision Insurance
ID Number
Subscriber Name/DOB
 

NOTICE OF PRIVACY PRACTICES
I acknowledge that I have read and received a copy of Marciano Family Optometric’s Notice of Privacy Practices as required by HIPAA regulations.
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ASSIGNMENT AND RELEASE
I, the undersigned, certify that I have insurance coverage with the fore mentioned insurance and assign directly to Marciano Family Optometric all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all co-pays and/or co-insurance. I also understand that if my insurance does not remit payment, I am responsible for any charges, whether paid or not paid by the insurance company. I, hereby, authorize the doctor to secure the payment of benefits and authorize the use of my signature on all insurance submissions.
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CONSENT FOR RELEASE OF MEDICAL INFORMATION(Required)
I agree to give my consent to Marciano Family Optometric to release medical conditions, test results, prescriptions, or medical records to the following individual(s). We will not honor disclosure of your medical information with anyone other than those stated without proper medical release forms on file.
Or, do not release information to anyone but myself
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Eye History
Date of Last Eye Exam:
Currently Wear Glasses:
Currently Wear Contacts: If so, How Many Hours a Day:
Reason for Today’s Visit:
 

Have you or a family member, experienced, or been treated for, any of the following? Check all that apply.

Cataracts(Required)
Cross Eye(Required)
Glaucoma(Required)
LASIK or RK/PRK(Required)
Lazy Eye(Required)
Macular Degeneration(Required)
Retinal Detachment(Required)

Are you currently experiencing, or have experienced, any of the following? Check all that apply.

Blurry Vision (Near)(Required)
Blurry Vision (Distance)(Required)
Burning(Required)
Discharge(Required)
Double Vision(Required)
Dryness(Required)
Excess Tearing / Watering(Required)
Eye Infection(Required)
Eye Pain or Soreness(Required)
Floaters or Spots(Required)
Halos(Required)
Headaches(Required)
Itching(Required)
Light Flashes(Required)
Light Sensitivity(Required)
Redness(Required)
Sandy or Gritty Feeling(Required)
Other(Required)
Medical History
Date of Last Physical Exam:
Primary Care Doctors Name:
Primary Care Doctors Number:
Pharmacy:
 
Have you or a family member experienced, or been treated for, any of the following? Check all that apply.

Marciano Family Optometric Wellness Form
Do you have a cough?
Do you have a fever now or have you in the past 14-21 days?
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
Are you experiencing shortness of breath or difficulty breathing?
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Have you experienced recent loss of taste or smell?
Have you taken a COVID-19 test and have not received the results at this time?
Have you tested positive for COVID-19 and have yet to re-test for a negative result?
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
(Signature and date only valid within 24 hours of appointment)
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RETURN POLICY(Required)
No refund will be made on professional services or procedures, including comprehensive eye
examinations, refractions, contact lens examinations, and medical office visits. Also, there are no
refunds on customized prescription eyeglasses, including frames and lenses. All lenses are customized
for you and can be remade if there is a doctor prescription change, but no refund will be given. Any
unopened boxes of contact lenses can be exchanged if your prescription changes, within a year of the
purchase.
Name
MM slash DD slash YYYY

To view our HIPPA policy please click here

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