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Maurice Sitel Test 2
Maurice Lapez
2021-03-16T19:32:24+00:00
Maurice Sitel Test 2
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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.
PATIENT INFORMATION
Exam Date
Date Format: MM slash DD slash YYYY
Name
*
Last Name
First Name
Gender
*
M
F
Birth Date
*
Date Format: MM slash DD slash YYYY
Address
*
Address
City
State / Province / Region
ZIP / Postal Code
Preferred Telephone Number
Preferred Telephone
*
Home
Work
Cell
Secondary Telephone Number
Secondary Telephone
Home
Work
Cell
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.
Employer
Occupation
Referred by
Email Address
*
Signature
*
Insurance Information
Plan Name
Group
Insured Name
First
Last
Relationship to Patient
Self
Spouse
Child
Insured ID#
Insured Date of Birth
Date Format: 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
Date Format: MM slash DD slash YYYY
From Dr.
Dr.
Miss
Mr.
Mrs.
Ms.
Prefix
First
Last
Do you or any of your blood relatives (i.e. Grandparents, Parents, Brother, or Sister) have any of these conditions?
Diabetes
Self
Relative
None
High Blood Pressure
Self
Relative
None
Thyroid Problems
Self
Relative
None
Heart Disease
Self
Relative
None
Asthma
Self
Relative
None
Cancer
Self
Relative
None
Glaucoma
Self
Relative
None
Cataracts
Self
Relative
None
Retinal Disease
Self
Relative
None
Eye Surgery
Self
Relative
None
Eye Injury
Self
Relative
None
Other
Self
Relative
None
Do you see double?
Yes
No
Frequent headaches?
Yes
No
Are you pregnant?
Yes
No
Eyes been dilated?
Yes
No
Year?
Primary Care Dr.
Dr.
Miss
Mr.
Mrs.
Ms.
Prefix
First
Last
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 no 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
*
Date Format: MM slash DD slash YYYY
HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, __________________________, have been presented with the Notice of Privacy Policy of Ariel Medina, and have been offered a copy of such policy to keep for my records.
HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
*
Please print full legal name here (the "Patient" or "Patient's legal representative")
I hereby acknowledge that I have been provided with a copy of the Policy.
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.
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.
Please initial here
Signature of Patient
*
Date
*
Date Format: MM slash DD slash YYYY
MEDICAL DIGITAL VIDEO AND PHOTO CONSENT
I, __________________________, 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.
MEDICAL DIGITAL VIDEO AND PHOTO CONSENT
*
Please print full legal name here (the "Patient" or "Patient's legal representative")
Signature of Patient
*
Date
*
Date Format: MM slash DD slash YYYY
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