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Mountain View Vision
Berenice
2022-05-18T15:11:22+00:00
Mountain View Vision
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Patient Registration Form
Name:
(Required)
Patient Last Name:
Patient First Name:
Gender:
(Required)
Male
Female
Decline to specify
Date of Birth:
(Required)
Month
Day
Year
Patient SSN:
(Required)
Name of Parent/Guardian (If Applicable):
Street Address:
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City:
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State:
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Zip:
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Email Address:
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Employer/School Name:
Occupation or Grade:
Home Phone:
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Cell Phone:
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Work Phone:
Preferred Language:
English
Spanish
Other
If other specify:
Preferred Contact Method:
(Required)
Email
Text Message
Mail
Phone
Marital status:
Married
Single
Divorced
Widowed
Prefer Not to Answer
Race/Ethnicity
Native American
Black/African American
Hispanic/Latino
Asian
White
Native Hawaiian/Pacific Islander
Prefer Not to Answer
Were you referred to our office by another medical provider?
Yes
No
Name of provider
Chief concern for visit, fill in box.
For patients 18 years old and under, please mark if you are experiencing any of the following:
Headaches
Loss of place when reading
Concerns about depth perception
Difficulty focusing
Difficulty with comprehension
Variable vision
Do you wear glasses?
Yes
No
Do you wear contacts?
Yes
No
If you answered ‘Yes’ above, please list the type of contacts you wear:
Name of Primary Care Provider:
Phone number:
Personal Medical & Eye History
Please check if you have or have had any of the following:
Eye injury
Surgery
Retinal detachment/holes
Flashes
Floaters
Eye turn/amblyopia
Dry eye
Macular degeneration
Glaucoma
Cataract
Cancer
Diabetes
High blood pressure
High cholesterol
Heart disease
Anxiety/depression
Autoimmune disease
Thyroid disease
Learning/reading difficulties
Alcohol use
Tobacco use
Other:
Other:
Type of surgery fill in the box:
Date of surgery:
MM slash DD slash YYYY
Name of surgery:
Are you taking any medications? (Prescription and over the counter)
Yes
No
Please list all prescription, over the counter and supplements.
Add
Remove
Do you have any medication allergies:
Yes
No
Please List:
Add
Remove
Family Medical & Eye History
Please check if you have any family members with following:
Cataract
Glaucoma
Macular degeneration
Eye turn/amblyopia
Retinal detachment
Diabetes
Cancer
Thyroid disease
Heart disease
High blood pressure
High cholesterol
Other:
Other:
Please let our office know of any special needs/requests to better assist in your exam:
Insurance Information. Please make a selection for both vision and medical insurance. Some of your care may be billed to your medical insurance. Your insurance cards will be scanned at your visit. If you have a secondary medical insurance, please also bring that information with you.
I have vision insurance
I do not have vision insurance
Vision Insurance:
(Required)
Subscriber’s Name:
(Required)
Subscriber’s Date of Birth:
(Required)
Month
Day
Year
Subscriber’s SSN:
(Required)
Insurance ID #:
(Required)
Employer:
(Required)
Insurance Information. Please make a selection for both vision and medical insurance. Some of your care may be billed to your medical insurance. Your insurance cards will be scanned at your visit. If you have a secondary medical insurance, please also bring that information with you.
I have medical insurance
I do not have medical insurance
Medical Insurance:
(Required)
Subscriber’s Name:
(Required)
Subscriber’s Date of Birth:
(Required)
Month
Day
Year
Subscriber’s SSN:
(Required)
Insurance ID #:
(Required)
Employer:
(Required)
Payment Policy: By making an appointment at Mountain View Vision, you are agreeing to abide by all billing policies of our practice. Payment is required at the time services are rendered or materials are ordered. Quotes of insurance coverage are based on information from the insurance company and are not guaranteed. Although we will gladly bill insurance for you, the patient remains responsible for their charges even after the insurance has been billed. If payment has not been received from insurance after 60 days, the patient will be expected to pay Mountain View Vision directly.
I agree to the Payment Policy.
Financial Responsibility: I understand that I am personally responsible for payment of my account even if I have insurance. If it becomes necessary to use a collection agency for any amount owed on this or subsequent visits, the undersigned agrees to pay all costs and expenses including reasonable attorney’s fees. Accounts assigned to collections will be charged a $50 collections fee.
I agree to the Financial Responsibility Policy.
Cancellation Fee: A cancellation charge of $50 will be billed to you personally if you do not provide at least 24 hours’ notice of a cancellation or change in your appointment date or time.
I agree to the Cancellation Fee Policy.
No Show Fee: A no show charge of $50 will be billed to you personally if you do not show for your scheduled appointment.
I agree to the No Show Fee Policy.
Release of Information: I hereby authorize release of my information to my insurance company or to any health care professional or education professional when necessary for my health care billing. (This allows us to bill your insurance.)
I agree to the Release of Information Policy.
Privacy Policy: We respect our legal obligation to keep health information private. We are obligated by law to give you notice of our privacy practices. If you would like to receive a copy of our Notice of Privacy Practices, please request one from the receptionist today or at any time in the future. I understand that Mountain View Vision has a Notice of Privacy Practices available for my review if I wish. At the present time, I acknowledge that this notice has been offered and I accept the Notice of Privacy Practices.
I agree to the Privacy Policy.
These policies will be enforced for both new patients and established patients. Our staff will be happy to answer any further question regarding these policies.
I agree to the policies.
By checking this box I acknowledge that I am electronically signing this document.
Type name
Date:
MM slash DD slash YYYY
Relationship to patient(if signed by Parent/Guardian)
RELEASE FOR INTERNAL EYE HEALTH EXAM
This form is intended to help you make an informed decision regarding your exam.
A thorough internal examination of the eye is integral to an eye examination and required by the doctors of Mountain View Vision. Without a thorough internal examination, serious eye disease can be missed, including but not limited to diabetes, retinal detachment, hypertension, or malignant tumors.
Your Doctor’s preferred method for this portion of the exam is an
Optomap retinal image
. The Optomap takes a digital image of the retina that can be viewed within moments by the Doctor and saved in your records.
The cost for the Optomap imaging is $42 (Adults, ages 18+) and $32 (Children under 18) and not typically covered by insurance.
Please select one of the following options:
I understand the importance of the Optomap retinal exam and agree to pay the out of pocket cost at the time of service. **Doctor preferred method**
I alternatively choose to have my eyes dilated with eye drops to allow my doctor to conduct the internal eye health exam.
Signature of Patient
By checking this box I acknowledge that I am electronically signing this document.
Type name
Date:
MM slash DD slash YYYY
Relationship to Patient (If Signed by a Parent/Guardian):
Are you interested in or currently wear contacts?
Yes
No
-
If No, please skip this page.
Contact Lens Fitting Agreement
To provide our patients with the highest standard of care, all patients are
REQUIRED
to have a comprehensive vision health examination by our doctors prior to the contact lens fitting or contact lens evaluation. The contact lens fitting is for new contact lens wearers or existing contact lens wearers who need substantial changes in lens design for health or vision reasons. The contact lens evaluation is for established contact lens wearers to ensure that the health of the eye has not been compromised and changes are necessary in the lens design or fit.
Contact Lens Fitting and Evaluation Fees:
Contact Lens Evaluation: $70
Mini Fit: $90 (for established patients with a small design or material change)
Spherical Fit: $125
Toric Fit: $155
Custom Toric Fit: $185
Multi-Focal Fit: $185
I understand that the contact lens prescription will be valid for
one year
and that an annual eye and contact lens examination will be required to update this prescription. I understand that wearing my contact lenses for more than the prescribed time or improper care increases my risk of infection, discomfort, and poor lens performance.
By checking this box I acknowledge that I am electronically signing this document.
Type name
Date:
MM slash DD slash YYYY
Dry Eye Symptoms and Severity
Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below.
Report the FREQUENCY that you experience the following symptoms:
Dryness, Grittiness or Scratchiness
Never
Sometimes
Often
Constant
Soreness or Irritation
Never
Sometimes
Often
Constant
Burning or Watering
Never
Sometimes
Often
Constant
Eye Fatigue
Never
Sometimes
Often
Constant
Report the SEVERITY of your symptoms:
Dryness, Grittiness or Scratchiness
No problems
Tolerable – not perfect but not uncomfortable
Uncomfortable – irritating but does not interfere with my day
Bothersome – irritating and interferes with my day
Intolerable – unable to perform my daily tasks
Soreness or Irritation
No problems
Tolerable – not perfect but not uncomfortable
Uncomfortable – irritating but does not interfere with my day
Bothersome – irritating and interferes with my day
Intolerable – unable to perform my daily tasks
Burning or Watering
No problems
Tolerable – not perfect but not uncomfortable
Uncomfortable – irritating but does not interfere with my day
Bothersome – irritating and interferes with my day
Intolerable – unable to perform my daily tasks
Eye Fatigue
No problems
Tolerable – not perfect but not uncomfortable
Uncomfortable – irritating but does not interfere with my day
Bothersome – irritating and interferes with my day
Intolerable – unable to perform my daily tasks
Do you use eye drops and/or ointment?
Yes
No
If yes, which drops/gel/ointment do you use?
Do you have fluctuating vision problems? (That can be corrected with blinking)
Never
Sometimes
Frequently
A Lot/Always
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