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

Mountain View Vision

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Patient Registration Form

Name:(Required)
Gender:(Required)
Date of Birth:(Required)
Preferred Language:
Preferred Contact Method:(Required)
Marital status:
Race/Ethnicity
Were you referred to our office by another medical provider?
For patients 18 years old and under, please mark if you are experiencing 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:
MM slash DD slash YYYY
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 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.
Subscriber’s Date of Birth:(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.
Subscriber’s Date of Birth:(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.
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 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.
No Show Fee: A no show charge of $50 will 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.
By checking this box I acknowledge that I am electronically signing this document.
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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 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:
Signature of Patient
MM slash DD slash YYYY
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.

By checking this box I acknowledge that I am electronically signing this document.
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
Soreness or Irritation
Burning or Watering
Eye Fatigue

Report the SEVERITY of your symptoms:

Dryness, Grittiness or Scratchiness
Soreness or Irritation
Burning or Watering
Eye Fatigue
Do you use eye drops and/or ointment?
Do you have fluctuating vision problems? (That can be corrected with blinking)
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