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WELCOME TO OUR OFFICE

PATIENT INFORMATION Date:______________________

Last Name_______________________________ First Name_______________________ Middle Initial__________Nickname________________________________

Home Phone ( ) _________________________Other Phone ( ) ____________________________________DOB______/______/______ Age: ____________

Marital Status_________________Spouse’s name:____________________________Email address:____________________________________________________

Address: ____________________________________________________ City: _____________________________State: _________Zip code:__________________

Employer/Occupation: ____________________________________________________________How did you hear about us: ________________________________

EYE/MEDICAL HISTORY

What is your reason for today’s visit: □ COMPREHENSIVE EYE EXAM □ CONTACT EXAM □ OTHER ____________________________________________

Last eye Exam Date__________________ Dr. ______________________________ Last Physical Exam ______________________Dr._________________________

Check all that apply: ____Blur at Distance ____Blur at Near ____Blur at Computer ____Eye Itch ____Eyes burn or Dry ____See “Flashes” ____See “Spots/Floaters”

Do you/have you worn glasses? YES NO Contacts? YES NO Type/Brand/Power? _________________________________________________________

How many nights sleep in lens? ___________ None How long each lens last: __________________Hours worn each day: ____________________________

List all medications you are currently taking or attach a list: ____________________________________________________________________________________

______________________________________________________________________________________________________________________________________

List all allergies / allergies to medication you have: _____________________________________________________________________________

Please check any conditions that apply to you or your family members:

EYE CONDITIONS MEDICAL CONDITIONS

Cataracts ___Me___ Family Diabetes ___Me___ Family

Glaucoma ___Me___ Family High Blood Pressure ___Me___ Family

Macular Degeneration ___Me___ Family Heart/Blood Disease ___Me___ Family

Eye Surgery ___Me___ Family For? _________ Breathing Problem ___Me___ Family

Eye Injury/ Trauma ___Me___ Family Cancer ___Me___ Family

Eye Disease ___Me___ Family Name? _______ Headache ___Me___ Family

Eye Infection ___Me___ Family is it reoccurring? Y or N Herpes ___Me___ Family

Lazy Eye (eye turn/amblyopia) ___Me___ Family HIV/AIDS ___Me___ Family

Double Vision ___Me___ Family Thyroid ___Me___ Family

Color Vision Problem ___Me___ Family Multiple Sclerosis ___Me___ Family

Depth Perception Problem ___Me___ Family Arthritis ___Me___ Family Other____________________________________ Other ____________________________________________

Are you pregnant? ____Y ____N Due date:___________________

Do you use tobacco? ___Y ___N Alcohol? ____Y ____N Ethnic:__________________________________Race:______________________________

INSURANCE INFORMATION

Insurance Co. name and address:________________________________________________________________________________________________________

Phone number listed on card for verification of benefit eligibility:______________________________________________________________________________

Name of Insured (Policy holder):______________________________________Patient’s Relation to Insured:___________________________________________

ID/ Policy / Subscriber number:_______________________________________Group or Employer Name & Group number:_______________________________

Policy holder’s D.O.B: _____/_____/_____ Policy holder’s SS#:________________________________________________________________________________

**Your insurance has a limit to what is being covered any amount over and beyond coverage is your responsibility to pay.

I have read and agreed to all of the conditions on this page and authorize examination and treatment (sign below)

Patient Signature- if Minor, Parent/Guardian: ____________________________________________________________________ Date _______________________

**Payment is due when professional services are rendered and are non-refundable**

ADDITIONAL SERVICES

**DILATED EXTENDED OPHTHALMOSCOPY: Consists of instilling drops onto your eye to make your pupil larger so the doctor can get a larger and better view of the inside of the eye. The doctor looks for signs of eye disease(s), such as diabetes, hypertension, glaucoma, cataracts, floaters, retinal abnormality, and neurological abnormality. It can also assist in diagnosing some headaches, and is important to perform for farsighted patients, especially children, to determine their prescription more accurately. Dilation drops last on average about 2 to 8 hours. It temporarily impairs near vision, increases light sensitivity and in most cases, not greatly decreases distance vision but you may need to pay extra attention if you drive afterwards.

*If you are pregnant or nursing, dilation will not be performed.*

Please initial one: ______I want dilation ______I refuse dilation (And I agree to assume all risks associated with failure to diagnose my eye condition due to lack of information, which may have been provided by this test)

**DIGITAL RETINAL PHOTOS (additional $10) A high resolution retinal photo a method of documentation of retinal findings, is more detailed and accurate than conventional hand drawn documentation. Digital retinal screening provides permanent documentation of eye disease and establishes baseline images to compare against any future changes.

Please initial one: ______Yes, I wished to have photos and not have to be dilated (additional $10) ______No, I do not wish to have photos

**AUTOMATED VISUAL FIELDS TESTING : This test maps out the retina’s sensitivity, checking for areas of sight loss in the central and peripheral visual fields. The objective of this more through test is to detect early signs of sight-threatening diseases, such as glaucoma, retinal disorders, optic nerve disease, and tumors of the visual pathway virtually all of the major causes of blindness in the Unites States can be detected by changes in the visual field.

Please initial one: ______ Yes, I wish to have this performed (additional $25-$60) ______No, I do not wish to have this performed

**RETINAL IMAGING OCT – Ocular Coherence Tomography (additional $50): This test provides high definition cross section of the retina and optic nerve to reveal early detection of potential sight threatening diseases of the eyes and changes at the cellular level of the layers of the eye that are not revealed with traditional exam methods.

We are committed to early detection and prevention of eye diseases. We strongly recommend these procedures to of our patients as part of their yearly comprehensive eye exam. If you decline any of the procedures above you are limiting our ability to accurately determine and monitor the health of your eyes. Early detection of eye disease is crucial.

Please initial one: ______Yes, I want my scan (additional $50) _______No, I do not want to scan

PATIENT PRIVACY NOTICE (HIPAA)

Patient privacy laws require providers to disclose the patient privacy statements and rules. Please read the copy of the ALMEDA VISION’S privacy rules and laws for your information.

By signing below, I have been informed and received ALMEDA VISION’S Patient Privacy Notice:

Please sign or initial: ________________________________________________________________________________________Date: ____________________

** FOR CONTACT LENS WEARERS- CONTACT LENS LIABILITY CONSENT**

I, the patient, assume all risks and responsibilities of wearing and maintaining my contact lenses. I will return on time for all follow-up visit(s) as directed by my eye doctor so that the contact lenses can be properly fitted on my eyes. There is an additional charge if I do not come back for follow-up visit(s) on time. I will follow my eye doctor’s contact lens wearing schedule and cleaning schedule as directed so that I will not compromise the health of my eyes. I will assume the responsibilities of knowing how to safely insert and remove my contact lenses. If I do not know or do not remember how to safely insert and remove contact lenses and clean my contact lenses, I will take the responsibility to have the entity selling me the contact lenses properly teach me. I assume all responsibilities of damage and harm for not using the proper contact lens and contact lens care system prescribed by my eye doctor. If my eye becomes red, irritated, or the vision changes with the contact lenses, I will discontinue wear and return immediately to my eye doctor. Remember, the Federal Drug Administration (FDA) classify contact lenses as medical devices. Contact lens fitting fee(s) is non-refundable. All contact lens follow-ups must be completed within the 1 month global period; otherwise, there will be an additional re-fit charge. The fee for late follow-up will range from $25 to $65 depending on how many months have passed, after 6 months a new exam may be required. Depending on the difficulty of the contact lens fit, the contact lens prescription may take more than a one-week follow-up visit to finalize. Contact lens prescription request may only be released once it is finalized. (Almeda Vision does not take any short cuts that may compromise the health of your eye and/or clarity of your vision)

I have read and agreed to all of the above terms for contact lens liability consent (sign below).

Patient Signature-if Minor, Parent/Guardian:____________________________________________________________________Date:_____________________

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