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Marciano Family Optometric
Berenice
2022-06-20T17:22:07+00:00
Marciano Family- West Palm
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Whom May We Thank for Your Referral?
Emergency Contact Name & Number
Insurance Information
Medical Insurance
ID Number
Subscriber Name/DOB
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Insurance Information
Vision Insurance
ID Number
Subscriber Name/DOB
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NOTICE OF PRIVACY PRACTICES
I agree to the privacy policy.
I acknowledge that I have read and received a copy of Marciano Family Optometric’s Notice of Privacy Practices as required by HIPAA regulations.
Name
(Required)
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
ASSIGNMENT AND RELEASE
I agree to the privacy policy.
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.
Signature
(Required)
Relationship to Party
(Required)
Date
(Required)
MM slash DD slash YYYY
CONSENT FOR RELEASE OF MEDICAL INFORMATION
(Required)
I agree to the consent for release of medical information.
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.
1.
Relationship
2.
Relationship
Or, do not release information to anyone but myself
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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:
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Remove
Have you had any eye surgeries or systemic surgeries since your last visit?
Have you or a family member, experienced, or been treated for, any of the following? Check all that apply.
Cataracts
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Cross Eye
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Glaucoma
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
LASIK or RP/PRK
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Lazy Eye
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Macular Degeneration
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Retinal Detachment
(Required)
Self
Family
N/A
If Family, Who?
(Required)
Please list any family members who have experienced/were treated for the condition listed above.
Are you currently experiencing, or have experienced, any of the following? Check all that apply.
Blurry Vision (Near)
(Required)
Currently Experiencing
Experienced in the Past
N/A
Blurry Vision (Distance)
(Required)
Currently Experiencing
Experienced in the Past
N/A
Burning
(Required)
Currently Experiencing
Experienced in the Past
N/A
Discharge
(Required)
Currently Experiencing
Experienced in the Past
N/A
Double Vision
(Required)
Currently Experiencing
Experienced in the Past
N/A
Dryness
(Required)
Currently Experiencing
Experienced in the Past
N/A
Excess Tearing / Watering
(Required)
Currently Experiencing
Experienced in the Past
N/A
Eye Infection
(Required)
Currently Experiencing
Experienced in the Past
N/A
Eye Pain or Soreness
(Required)
Currently Experiencing
Experienced in the Past
N/A
Floaters or Spots
(Required)
Currently Experiencing
Experienced in the Past
N/A
Halos
(Required)
Currently Experiencing
Experienced in the Past
N/A
Headaches
(Required)
Currently Experiencing
Experienced in the Past
N/A
Itching
(Required)
Currently Experiencing
Experienced in the Past
N/A
Light Flashes
(Required)
Currently Experiencing
Experienced in the Past
N/A
Light Sensitivity
(Required)
Currently Experiencing
Experienced in the Past
N/A
Redness
(Required)
Currently Experiencing
Experienced in the Past
N/A
Sandy or Gritty Feeling
(Required)
Currently Experiencing
Experienced in the Past
N/A
Other
(Required)
Currently Experiencing
Experienced in the Past
N/A
If other, explain:
(Required)
Medical History
Date of Last Physical Exam:
Primary Care Doctors Name:
Primary Care Doctors Number:
Pharmacy:
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Remove
Have you or a family member experienced, or been treated for, any of the following? Check all that apply.
AIDS / HIV
Allergies
Arthritis
Asthma
Blood / Lymph Disorder
Cancer
Diabetes
Ears, Nose, Throat Conditions
Gastrointestinal Conditions
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Lupus
Neurological Conditions
Psychiatric Disorder
Seizures
Skin Conditions
Stroke
Thyroid Dysfunction
Current Medications :
Allergic to any Medications:
Hobbies:
Sports:
Are you Pregnant or Nursing? :
Do you smoke:
How often?
Do you drink:
How often?
Height:
Weight:
Marciano Family Optometric Wellness Form
Do you have a cough?
Yes
No
Do you have a fever now or have you in the past 14-21 days?
Yes
No
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?
Yes
No
Are you experiencing shortness of breath or difficulty breathing?
Yes
No
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?
Yes
No
Have you experienced recent loss of taste or smell?
Yes
No
Have you taken a COVID-19 test and have not received the results at this time?
Yes
No
Have you tested positive for COVID-19 and have yet to re-test for a negative result?
Yes
No
Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
Yes
No
Signature
(Required)
(Signature and date only valid within 24 hours of appointment)
Date
(Required)
MM slash DD slash YYYY
RETURN POLICY
(Required)
I agree to the return policy.
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
First
Last
Signature
(Required)
Date
MM slash DD slash YYYY
To view our HIPPA policy please click here
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