Patient Registration Form – Dr. Medina’s Optical – Patient Registration Forms

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Patient Registration Form – Dr. Medina’s Opticaladmin2017-07-06T01:14:23+00:00

Dr. Medina's Optical

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Patient Information
Date
MM slash DD slash YYYY
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary phone
Secondary phone
Email
Employer
Occupation
Referred by
Insurance Information
Plan Name
Group
Name of Primary Insured
Last Four Digits of Primary Insured's SSN:
Insured ID#
Insured date of birth
MM slash DD slash YYYY
Relationship to the patient
- Self
- Spouse
- Child
Medical and Ocular History
What is the reason for today's visit?
Are you planning to get new glasses today?
- Yes
- No
Are you planning to get new contact lens today?
- Yes
- No
Age of present glasses
Age of sunglasses
New patient?
- Yes
- No
Date of last eye exam
MM slash DD slash YYYY
Doctor of last visit
Do you or any of your blood relatives (i.e., grandparent, parents, brother, or sister) have any of these conditions?
- Diabetes
- High blood pressure
- Thyroid problems
- Heart Disease
- Asthma
- Cancer
- Glaucoma
- Cataracts
- Retinal Disease
- Eye surgery
- Eye injury
- Other
Please explain any positive findings.
Do you see double?
- Yes
- No
Frequent headaches?
- Yes
- No
Are you pregnant?
- Yes
- No
Eyes been dilated?
- Yes
- No
Year of dilation
Primary care physician
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, medications, or other? If yes, please explain:

HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, the undersigned (the "Patient" or "Patient's legal representative"), can be presented with the Notice of Privacy Policy of Dr. Ariel Medina, and can be offered a copy of such policy to keep for my records.
- I hereby acknowledge that I have been provided with a copy of the Policy.
- 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.
Signature
Date
MM slash DD slash YYYY
MEDICAL DIGITAL VIDEO AND PHOTO CONSENT
I, the undersigned (the "Patient" or "Patient's legal representative") 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.

Please provide full legal name here (the "Patient" or "Patient's legal representative")
Signature of Patient
Date
MM slash DD slash YYYY

Contact Lenses
I, the undersigned (the "Patient" or "Patient's legal representative") understand that the use of contact lenses can cause eye irritations, infections and corneal injury, The risk among extended wear lens users increases with the number of consecutive days that the lenses are worn between removals. If my eyes become red and irritated or if my vision worsens while wearing lenses, I will immediately remove the lenses and consult my eye care practitioner. I understand that in order to receive a prescription for contact lenses, I must return for the follow up exam(s). If I use monovision contact lenses, I will wear a pair of spectacles with an over-correction for tasks which require full binocular distance correction such as driving or operating machinery. Monovision can cause headaches and decrease in depth perception.
Signature
Date
MM slash DD slash YYYY
Dilation Consent
It is our goal to provide you a complete and thorough comprehensive eye examination. To effectively accomplish our goal, we feel it is important to dilate the pupils of your eyes. This will require placing drops in your eyes which will open the pupil (black spot) and allow a better view of the inside of your eye. As with many medications, there are some side effects of the drops used to dilate the pupil, These include sensitivity to light and blurred reading (in most cases the distance vision will be unaffected). The side effects usually last from 2-3 hours and in some cases as long as 24 hours. While we believe dilation is an important part of the eye examination process, we understand that you may not want to, defer or omit this procedure.
- I wish to be dilated today
- I do not wish to be dilated at this time but will return within 90 days from today (no additional charge for dilation)
- I do not wish to be dilated and agree to hold Dr. Ariel Medina harmless as a result of my actions
I understand the risks and benefits associated with pharmacologic dilation of the pupils and have made my decision via informed consent.
Signature
Date
MM slash DD slash YYYY

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.
- I understand the policy as described above.
PRESCRIPTION LENSES
We guarantee that your lenses will be made and inspected to the specification of the prescription given.
- I understand the policy as described above.
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 not effect on vision. Dispensing fees will apply with replacement of lenses.
- I understand the policy as described above.
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.
- I understand the policy as described above.
CANCELLATION POLICY
Patient has 24 hours to cancel the order. See sales associate for details.
- I understand the policy as described above.
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.
- I understand the policy as described above.
Patient Name
First Last
Patient Signature
Date
MM slash DD slash YYYY

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