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Sitel Mike Training
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2020-05-27T21:41:19+00:00
Sitel Mike Training
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HIPAA PRIVACY ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I,
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
(Patient's or Patient's legal representative Full legal name here)
, 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.
I hereby acknowledge with my signature that I have been provided with a copy of the Policy. [Please Initial Here]
I hereby refuse to acknowledge receipt of the Policy. I understand that even though I may refuse to sign this acknowledgement, Provider may still provide treatment to me. [Please Initial Here]
*
Signature of Patient.
*
Date
*
MM slash DD slash YYYY
MEDICAL DIGITAL VIDEO AND PHOTO CONSENT
I,
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
First
Middle
Last
(Patient's or Patient's legal representative Full legal name here)
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.
Signature of Patient.
*
Date
*
MM slash DD slash YYYY
PATIENT INFORMATION
EXAM DATE
*
MM slash DD slash YYYY
*
LAST NAME
FIRST NAME
*
M
F
BIRTH DATE
*
MM slash DD slash YYYY
*
ADDRESS
CITY
STATE/PROVINCE
ZIP/POSTAL CODE
PREFERRED TELEPHONE NUMBER
*
Select one
*
HOME
WORK
CELL
SECONDARY TELEPHONE NUMBER
*
Select one
*
HOME
WORK
CELL
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.
EMPLOYER
*
OCCUPATION
*
REFERRED BY
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
EMAIL ADDRESS
*
SIGNATURE
INSURANCE INFORMATION
PLAN NAME
*
GROUP
*
INSURED NAME
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
RELATION TO PATIENT:
*
SELF
SPOUSE
CHILD
(CHECK ONE)
MEDICAL AND OCULAR HISTORY
WHAT IS 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 THE LAST EYE EXAM
*
MM slash DD slash YYYY
FROM DR.
*
First
Middle
Last
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
*
Select All
SELF
RELATIVE
NONE
HIGH BLOOD PRESSURE
*
Select All
SELF
RELATIVE
NONE
THYROID PROBLEMS
*
Select All
SELF
RELATIVE
NONE
HEART DISEASE
*
Select All
SELF
RELATIVE
NONE
ASTHMA
*
Select All
SELF
RELATIVE
NONE
CANCER
*
Select All
SELF
RELATIVE
NONE
GLAUCOMA
*
Select All
SELF
RELATIVE
NONE
CATARACTS
*
Select All
SELF
RELATIVE
NONE
RETINAL DISEASE
*
Select All
SELF
RELATIVE
NONE
EYE SURGERY
*
Select All
SELF
RELATIVE
NONE
OTHER
Select All
SELF
RELATIVE
NONE
DO YOU SEE DOUBLE?
*
YES
NO
FREQUENT HEADACHES?
*
YES
NO
ARE YOU PREGNANT?
*
YES
NO
EYES BEEN DILATED?
*
YES
NO
YEAR?
*
PRIMARY CARE DR.
*
First
Middle
Last
PLEASE EXPLAIN ANY POSITIVE FINDINGS:
*
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, MEDICATION OR OTHER? IF YES, PLEASE EXPLAIN.
Dr. Medina Optical
F͟R͟A͟M͟E͟S͟
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.
P͟R͟E͟S͟C͟R͟I͟P͟T͟I͟O͟N L͟E͟N͟S͟E͟S͟
We guarantee that your lenses will be made and inspected to the specification of the prescription given.
C͟O͟A͟T͟I͟N͟G͟S͟
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.
N͟O͟N͟-A͟D͟A͟P͟T͟ P͟O͟L͟I͟C͟Y͟
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.
C͟A͟N͟C͟E͟L͟L͟A͟T͟I͟O͟N͟ P͟O͟L͟I͟C͟Y͟
Patient has 24 hours to cancel the order. See sales associate for details.
O͟U͟T͟S͟I͟D͟E͟ D͟O͟C͟T͟O͟R͟'͟S͟ C͟H͟A͟N͟G͟E͟
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's Signature
*
Print Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Middle
Last
Date
*
MM slash DD slash YYYY
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