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Reynaldo Sitel Test 2
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2020-05-27T21:40:49+00:00
Reynaldo Sitel Test 2
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HIPAA PRIVACY ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Name
First
Last
I have been presented with the Notice of Privacy Policy of Dr. Ariel Medina, and have been offered a copy of such policy to keep for my records.
Signature
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I hereby acknowledge that I have been provided with a copy of the Policy
Patient initials
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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.
Patient initials
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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.
Patient signature
Date
MM slash DD slash YYYY
Exam Date
MM slash DD slash YYYY
Patient Name
First
Last
Sex
Male
Female
Birth Date
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Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Preferred telephone number
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
Secondary telephone number
Work
Home
Cell
Phone
Employer
Occupation
Referred by
Email address
Signature
Insurance information
Plan name
Group
Insured name
First
Last
Relationship to patient (Check one)
Self
Spouse
Child
Insurance ID#
Insured date of birth
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Medical and ocular history
What's 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
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From Dr.
Previous patient?
Yes
No
Do you or any of your blood relatives (i.e. Grandparents, parents, brother or sister) have any of these conditions?
Diabetes
High blood pressure
Thyroid problems
Heart Desease
Asthma
Cancer
Glaucoma
Cataracts
Retinal disease
Eye surgery
Eye injury
Other
Do you see double?
Yes
No
Frecuent headaches?
Yes
No
Are you pregnant?
Yes
No
Eyes been dilated?
Yes
No
Year?
Primary care doctor
Please explain any positive findings
Are you taking any eyedrops (Prescription or over the counter)? Please list
Are you taking any other medication? (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 not 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 name
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Signature
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