Welcome Form HiddenDate MM slash DD slash YYYY WELCOME TO ALAMEDA EYES OPTOMETRYAll questions contained in this questionnaire are strictly confidential and will become part of your medical record. If you prefer to print the form at home to bring with you to your next appointment please CLICK HEREName(Required) First Middle Last 1 M F Date of Birth MM slash DD slash YYYY Age Driver’s License Social Security NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code HomeWorkCellEmail(Required) Employer Occupation Patient Communication HOME WORK CELL TEXT EMAIL (What is your preferred method of communication)Hobbies How did you hear about us? INSURANCE ON-LINE ADVERTISEMENT FAMILY/FRIEND Referred By INSURANCE INFORMATIONVision InsuranceInsured’s Name Insured’s Date of Birth MM slash DD slash YYYY Relationship Insured’s Employer Insured’s Provider Insured’s Member ID# Medical Insurance Insured’s Name Insured’s Date of Birth MM slash DD slash YYYY Relationship Insured’s Employer Insured’s Provider Insured’s Member ID# HIPPA- PATIENT CONFIDENTIALITYInsurance Billing I hereby authorize ALAMEDA EYES OPTOMETRY to release any medical or other information necessary to process insurance claims. I also request payment of government benefits to ALAMEDA EYES OPTOMETRY when they accept the assignment.Insurance Liability I understand that my insurance carrier may not pay for all the services and/or materials provided by this office. I will assume responsibility for all the fees not paid to ALAMEDA EYES OPTOMETRY by my insurance carrier. I agree that if my employer, insurance carrier or plan sponsor denies payment to all or any portion of my claim, I will be financially responsible for all outstanding charges. Authorization obtained at the time of service does not guarantee payment and any denied services will be balanced and billed to the patient.Notice of HIPPA Compliance In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct healthcare operations involving our office. The complete Notice of Privacy Practices is available on the request and is also posted on our website at www.alamedaeyes.com.VISION QUESTIONNAIREDESCRIBE ANY PROBLEMS YOU ARE HAVING WITH YOUR EYES OR VISION Add RemoveDO YOU WEAR CONTACT LENSES? Yes No DO YOU WEAR CONTACT LENSES? SOFT HARD MODALITY DAILY BI-WEEKLY MONTHLY TYPE ASTIGMATISM/TORIC PRESBYOPIA/ MULTI-FOCAL WHAT BRAND CONTACTS DO YOU WEAR? DO YOUR EYES FEEL DRY WITH THE CONTACTS ON? Yes No DO YOU FEEL LIKE YOUR VISION WITH THE CONTACTS HAVE CHANGED? Yes No DO YOU STILL FEEL COMFORTABLE WITH THE CONTACT LENSES? Yes No CONTACT LENS EVALUATIONA contact lens is a medical device that can affect the health of the eye; therefore, it must fit appropriately to avoid damage to the eye. Since follow-up care is essential, it is your responsibility to keep all appointment and follow all lens care instructions.I understand that my contact lens prescription is only valid for ONE YEAR. All patients are required to come in for an annual contact lens exam. This is necessary to assure that my eyes are healthy and the contact lenses are still fitting well. Contact lens prescriptions cannot be renewed without an annual exam. Contact lens exams have a separate charge ($55-$140, depending on the complexity) that is NOT included in the comprehensive eye exam. I have read and understand the purpose of the contact lens evaluation and the additional charges. I choose to PROCEED with the contact lens evaluation and am aware that the fitting fee includes follow-up care within the first 90 days of my last eye exam.Patient Signature(Required)OCT & OPTOSDigital imaging is taken of the back of the eyes to provide a wider field of vision of the retina. The imaging provided will help the doctor assess the health of the eyes as well as aid for early detection. The imaging will be kept on record which can be used to compare/review any possible changes that may change in your future exams. OCT & OPTOS imaging is an additional $39 and is recommended yearly to compliment your annual eye exam. Consent I have read and understand the purpose of the OCT & OPTOS. I choose to ACCEPT and pay the additional fee of $39.Consent I have read and understand the purpose of the OCT & OPTOS. I choose to DECLINE.Patient SignatureCONSENT OF ACKNOWLEDGMENTS I have read, understood, and filled out the following forms as the Patient/Guardian for the purpose of signing this document, hereby accepting its terms. I have answered the above questions to the best of my knowledge. I understand that I am responsible for payment at the time of service. THIS FORM HAS BEEN ELECTRONICALLY SIGNEDPatient/Guardian SignaturePLEASE ALSO FILL OUT PART 2This is a 2 part document. Please also fill out the New Patient Medical History Form Part 2