Vista Eye Associates


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  • Patient Information

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  • Primary Insurance

    Please bring all medical and vision insurance cards with you to your appointment.
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  • Your Eye Health Information

  • Glasses/Contact Lens History

  • Patient Medical History

  • Have you ever had any of the following eye conditions):

  • Please list all medical conditions past or present (Diabetes, High Blood Pressure, High Cholesterol, Heart Problems, Arthritis, Asthma etc.)

  • Is there a family medical history of any of the following (blood relatives only):

  • Authorized Access/Policies/Insurance/HIPPA

  • By signing this form, I consent to treatment for myself or on behalf of the Minor for which this information pertains. I give permission for the doctor/s to examine, diagnose and initiate treatment as deemed appropriate. I further attest that if I am signing on behalf of Minor that I am the Parent or Legal Guardian of the Minor and have the authority to authorize care and treatment.


  • Consent: I understand that there is a risk involved with wearing contact lenses. I have read the above information and have been trained in the handling and care of my contact lenses and am aware of potential complications.

  • Contact Lens Prescription Signed Acknowledgment Form

    Included below is important information to review prior to receiving your contact lens prescription.
  • The Centers for Disease Control and Prevention (CDC) makes clear, "Contact lenses can provide many benefits, but they are not risk-free-especially if contact lens wearers don't practice healthy habits and take care of their contact lenses and supplies. If patients seek care quickly, most complications can be easily treated by an eye doctor. However, more serious infections can cause pain and even permanent vision loss, depending on the cause and how long the patient waits to seek treatment." The CDC recommends the following for contact lens wearers: ✓ Schedule a visit with your eye doctor at least once a year. ✓ Take out your contacts and call your eye doctor if you have eye pain, discomfort, redness, or blurry vision. ✓ Understand that eye infections that go untreated can lead to eye damage or even blindness. The Food and Drug Administration (FDA) indicates: "To be sure that your eyes remain healthy you should not order lenses with a prescription that has expired or stock up on lenses right before the prescription is about to expire. It's safer to be re-checked by your eye care professional. "3 Symptoms of Eye Infection include: Irritated, red eyes Worsening pain in or around the eyes—even after contact lens removal Light sensitivity Sudden blurry vision Unusually watery eyes or discharge • Sign below to acknowledge that you were provided with a copy of your contact lens prescription at the completion of your contact lens fitting.
  • Health Information Protection