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Mountain View VisionBerenice2022-05-18T15:11:22+00:00

Mountain View Vision

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Name:(Required)
Gender:(Required)
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Preferred Language:
Preferred Contact Method:(Required)
Marital status:
Race/Ethnicity
Were you referred to our office by another medical provider?
Please check if you have any of the following:
Do you wear glasses?
Do you wear contacts?

Personal Medical & Eye History

Please check if you have or have had any of the following:
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Are you taking any medications? (Prescription and over the counter)
Please list all prescription, over the counter and supplements.
Do you have any medication allergies:
Please List:

Family Medical & Eye History

Please check if you have any family members with following:
Insurance Information. Please fill out both vision and health insurance. Some of your care may be billed to your health insurance.
Insurance Information. Please fill out both vision and health insurance. Some of your care may be billed to your health insurance.
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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.


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.

Cancellation Fee: A cancellation charge of $50 may be billed to you personally if you do not provide at least 24 hours’ notice
              of a cancellation or change in your in your appointment date or time.


No Show Fee: A no show charge of $50 may be billed to you personally if you do not show for your scheduled appointment.


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.)


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.

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.

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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.  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:
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Are you interested in or currently wear contacts?

-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.

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Digital Eye Fatigue

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 of dry eye symptoms you are experiencing by checking Never,
Sometimes, Often or Constant using the numbering system below:

0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant

Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue

Report the SEVERITY of your symptoms using the ratings list below:

0 = No problems
1 = Tolerable – not perfect but not uncomfortable
2 = Uncomfortable – irritating but does not interfere with my day
3 = Bothersome – irritating and interferes with my day
4 = Intolerable – unable to perform my daily tasks

Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Do you use eye drops and/or ointment?

Have you been told that you have blepharitis or have you been treated for a stye?

Blepharitis
Stye
Do you have fluctuating vision problems? (That can be corrected with blinking)
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