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Welcome to Beverly Hills OptometryToday’s Date: Date of birth:__________________________ Sex: M/FPatient Name: Mr. Mrs. Ms. Miss. Dr.______________________________________________________________________________ Parent/Guardian Name (if patient is a minor)_______________________________________________________________________Address:____________________________________________ City:____________________ State:__________Zip Code:_________Phone: Home: (_______)_______________ Cell: (________)___________________ Work: (______)__________________________ Email:______________________________ Occupation:_______________________ Hobbies________________________________Emergency Contact: Name:_________________________ Relationship:___________________ Phone:________________________How did you hear about us? ______________________You are interested in: ____Comprehensive Eye Exam ____Contact Lens Evaluation ____Laser Vision Correction ____Advance Comprehensive Eye Exam (includes Retinal Photo) ____Other Eye ConditionInsurance Information(Please present any vision/medical cards at check in)Vision: (Please Circle) Eyemed Superior VSP Avesis Spectera Cigna Other_____________________________________Name (of primary insured): ________________________________ Date of Birth:_______________ Last 4 of SS#_________Medical PPO: (Please Circle) BlueCross BlueShield Aetna Medicare Cigna United Other__________________________Name (of primary insured): ________________________________ Date of Birth:_______________ Last 4 of SS#_________Medical InformationDo you wear: Glasses -> Distance/Computer/Reading/Bifocal/Progressive Contacts -> Daily wear/Extended wear/ Astigmatism/Multifocal/Monovision/soft/rigid gas permSatisfaction with current glasses/contacts: Low 1 2 3 4 5 6 7 8 9 10 HighList any injuries or surgeries to your eyes:__________________________________________________________________________List any medications, supplements, and/or over-the-counter medications you are currently using:____________________________________________________________________________________________________________Do you have any allergies to medications: Y/N if yes, please list:________________________________________________________Do you have any seasonal/food allergies: Y/N if yes, please list:_________________________________________________________Do you: _____smoke? _____drink alcohol? _____abuse substances? How often? ________________________________________Please check any of the following that apply and circle for you (S) or family member (F):__Blur at distance__Eye Fatigue __Problems with glare __High Blood Pressure (S/F) __Glaucoma (S/F)__Blur at near__Eye Strain __Sensitive to light __Diabetes (S/F) __Cataracts (S/F)__Blur after reading__Eyes itch __Seeing spots __Thyroid (S/F) __Color blindness (S/F)__Double vision __Eyes water __Asthma (S/F) __Lazy Eyes (S/F) __HIV+/AIDS (S/F) __Headaches __Light flashes __Dry Eyes __Cancer______(S/F) __Macular Degeneration (S/F) __Pregnant__mo __OtherFamily History of Eye Disease: Y/N If yes, explain ____________________________________________________________________Family History of Diabetes: Y/N If yes, explain_ ______________________________________________________________________Statement of Patient Financial ResponsibilityThe service that you have elected to participate in implies a financial responsibility on your part. This responsibility obligates you to ensure payment in full for our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. Verification of benefits is not a guarantee of payment. You are responsible for any deductibles or co-payments as determined by your insurance carrier. These fees are due at time of service. You are further responsible for any amounts not covered by your insurance.I have read the above policy regarding my financial responsibility to Dr. Kambiz Silani, O.D., for providing eye care services to the above named patient or myself. I certify that the information is, to the best of my knowledge, true and accurate. I authorize my insurer to pay any benefits directly to Dr. Kambiz Silani, O.D. for the full amount that is incurred by the above patient or myself.Patient Signature______________________________________________ Date ____________________Parent Signature ______________________________________________ Date ____________________Consent for Treatment and Authorization to Release InformationI hereby authorize Dr. Kambiz Silani, O.D. to perform or have performed upon me, or the above named patient, appropriate assessment and treatment procedures.I further authorize Dr. Kambiz Silani, O.D. to release to appropriate agencies, any information required in the course of my, or the above named patient’s, examination and treatment.Patient Signature______________________________________________ Date ____________________Parent Signature ______________________________________________ Date ____________________Consent for Retinal Digital PhotographyHave you ever wanted to see what the back of your eye looks like? Get a detailed, expert description of the unique fingerprint of your retina and its structures. This is particularly useful for early detection, monitoring, and/or treatment of eye and body conditions like macular degeneration, diabetes, glaucoma, high blood pressure, high cholesterol, some cancers and many more. It serves as a great tool for preventative medicine. Strongly recommended for first time patients OR patients with a personal/family history of any of the above mentioned. The service that you have elected to participate in implies a financial responsibility on your part. This responsibility obligates you to ensure payment in full for our fees. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. Verification of benefits is not a guarantee of payment. You are responsible for any deductibles or co-payments as determined by your insurance carrier. These fees are due at time of service. You are further responsible for any amounts not covered by your insurance.I have read the above policy regarding my financial responsibility to Dr. Kambiz Silani, O.D., for taking a digital photograph of my Retina.Patient Signature______________________________________________ Date ____________________Parent Signature ______________________________________________ Date ____________________ ................
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