VVO Patient Registration Form

Vivid Visions Optometry, Inc is an independent optometry corporation, located on 27201 Tourney Rd. Suite 100, Valencia, CA 91355 inside the Valencia Executive Plaza. As an independent practice, Vivid Visions Optometry, Inc has a responsibility to establish its own methods of patient care, consistent with the laws governing the practice of optometry in California.

Vivid Visions Optometry, Inc offers comprehensive eye exams, contact lens exams, custom contact lens fittings, ocular health evaluations, comprehensive binocular vision evaluations and sports vision evaluations. Vivid Visions Optometry, Inc also offers evaluations, management, and treatments for sight-threatening ocular diseases, ocular misalignments, headaches, migraines, concussions, traumatic brain injury, and reading and learning dysfunctions.

Vivid Visions Optometry, Inc carries a wide selection of high-quality eyeglasses frames and lenses to suit your style, needs, and budget. If you prefer contact lenses, you also have a range of contact lens options, including daily disposables, extended wear, and specialty lenses, to cater to your unique requirements.
PATIENT PERSONAL INFORMATION
First Name*
Last Name*
Gender*

MaleFemaleN/AOther
Date of Birth*

MonthDayYear
Date
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Have you had an examination, consultation, or treatment by Vivid Visions Optometry, Inc in the last year AND has your personal information stayed the same since your last visit?*

YesNo
Home Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Work/Office Phone
EMERGENCY CONTACT
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
RESPONSIBLE PARTY
Is the patient present with a caregiver who is responsible for the patient?

YesNo
Responsible Party Name
Responsible Party Date of Birth

MonthDayYear
Date
Responsible Party Phone
Responsible Party Relationship
VISION INSURANCE
We accept most vision insurance plans. Will you be using vision insurance benefits towards your eye examination?*

YesNo
Vision Plan Insurance Name
Vision Plan Group/Plan Name
Vision Plan Insured Name
Vision Plan Insured Date of Birth

MonthDayYear
Date
Vision Plan Insured ID
Vision Plan Insured SSN (Last 4 Digits)
Vision Plan Insured Relationship
How did you hear about us?*

Walk-InProfessional ReferralFamily / Friend ReferralSocial MediaOther
Who referred you?
First Name, Last Name of person who referred you
Please select all visual and ocular complaints that apply.*

NO VISUAL COMPLAINTS: No visual or ocular complaintsVISUAL CLARITY: Blurry vision or hazy visionHEADACHE-RELATED: Headaches or migrainesBALANCE AND MOTION-RELATED: Dizziness, nausea, or motion sicknessVISUAL STABILITY: Jumpy vision, shaky vision, unstable vision or unstable focus; vision goes in and out of focusVISION DISTORTION: Vision turns white, vision turns black, vision zooms in and outVISUAL DISTORTION: Distorted vision or seeing distortions in size/shapeLIGHT SENSITIVITY: Glare sensitivityEYE ALIGNMENT: Strabismus, eyes drift or crossEYE ALIGNMENT: Double vision or diplopiaAMBLYOPIA-RELATED: Amblyopia or lazy eyeOCULAR DISCOMFORT: Eye pain, eye straining or eye pullingREADING-RELATED: Skip lines when reading, lose place when reading, words move on the page when readingVISUAL ABERRATIONS: Flashing lights or colorful lights in vision, shadow in visionOCULAR SURFACE: Dry, irritated, or burning eyes, itchy or watery eyes, foreign body sensationCOGNITIVE/VISUAL PROCESSING: Brain fogDEPTH AND SPATIAL JUDGMENT: Difficulty judging depth or space or clumsinessBALANCE AND COORDINATION: Difficulty with balance, difficulty with hand-eye coordinationVISUAL FIELD: Visual field lossVISION LOSS: Vision lossEYELIDS: ptosis or lid droopOther
You may have a Binocular Vision Dysfunction

Based on your symptoms and/or ocular/medical history, an additional Comprehensive Binocular Vision Evaluation is strongly recommended by our doctor to be scheduled at a later date!

The Comprehensive Binocular Vision Evaluation, which takes place over a seperate hour long visit, includes an in-depth evaluation of your ocular alignment, eye movement skills, focusing skills, eye teaming skills, and sensorimotor skills. Without the additional evaluation, our doctor may not be able to diagnose nor treat your binocular vision dysfunction with special lenses (prisms) and/or vision therapy (personalized eye training program
Please select all ocular and medical conditions that apply to you.*

GENERAL: CancerENDOCRINE: DiabetesENDOCRINE: Thyroid issuesCARDIOVASCULAR: High blood pressureCARDIOVASCULAR: High cholesterolCARDIOVASCULAR: POTS (Postural Orthostatic Tachycardia Syndrome)CARDIOVASCULAR: History of strokeEYE: Macular degenerationEYE: History of lazy eye or strabismus, patching, or vision therapyEYE: Retinal problemsNEUROLOGIC: ADHDNEUROLOGIC: Autism Spectrum DisordersNEUROLOGIC: Migraine or headachesPSYCHIATRIC: Panic disorderPSYCHIATRIC: AnxietyTRAUMA: Traumatic brain injury, head injury, sports injury, automobile/bike accidents, or concussionsSKIN/CONNECTIVE TISSUE: EDS (Ehlers-Danlos Syndrome) or other connective tissue problemsFAMILY OCULAR HISTORY: Family history of glaucomaFAMILY OCULAR HISTORY: Family history of lazy eye or strabismusFAMILY MEDICAL HISTORY: Family history of migraine or headachesFAMILY MEDICAL HISTORY: Family history of anxiety or panic attacksFAMILY MEDICAL HISTORY: Family history of macular degenerationOther
Please include a list of medications or supplements you are currently taking, ocular or systemic. *
Please select all allergies that apply to you.*

GENERAL OR MEDICATION ALLERGIES: no general or medication allergiesALLERGIES: seasonal allergiesALLERGIES: medical equipment allergiesALLERGIES: medication allergiesOther
Have you had a Dilated Eye Exam in the last two years?*

YesNo
PUPIL DILATION

Based on your symptoms and/or ocular/medical history, performing a Comprehensive Eye Exam (Glasses Rx and Dilated Ocular Health Evaluation) is strongly recommended by our doctor! Dilation is the process of instilling three dilating eye drops to enlarge the pupil to examine the internal structures of the eye for signs of disease, which is important for your health and well- being. Without dilating the eye, your doctor may not be able to detect cases in which the retina is diseased, physically compromised, or harboring cancerous growths. As such, early detection and diagnosis of certain eye conditions, along with timely and effective treatment, may not be possible.

✔️ I understand the importance of dilation.
ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY

✔️ I understand that it is my responsibility to supply the Practice with current insurance information and/or any referral authorization forms that may be necessary for my insurance.

✔️ I understand that vision and/or medical insurance coverage is not a guaranteed form of payment. I am aware that if I have a routine diagnosis, my insurance may not cover the examination. Any and all specialty testing performed to diagnose or manage eye diseases are separate billable fees. Authorization obtained at time of service does not guarantee payment. I assign and authorize payments to Vivid Visions Optometry, Inc.

✔️ I understand my employer, insurance carrier, or plan sponsor, may not approve or reimburse my vision and/or medical services in full due to usual and customary rates, benefit exclusions coverage limits, lack of authorization or medical necessity.

✔️ I understand that I am responsible for fees not paid in full, co-payments, policy deductibles and co-insurance except where my liability is limited by contract or State or Federal law. I understand that balances left unpaid may result in being sent to collections, and/or termination from care at Vivid Visions Optometry, Inc.

✔️ I understand that all expenses need to be paid at the time services and/or material are rendered.
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT TO DISCLOSE MEDICAL INFORMATION

✔️ I acknowledge that I have received the Notice of Privacy Practices from Vivid Visions Optometry, Inc.

✔️ I authorize Vivid Visions Optometry, Inc to disclose my medical information to insurers and providers outside of the Practice when necessary for purposes of my treatment, payment for that treatment, and for their health care operations.

✔️ I voluntarily give my permission to Vivid Visions Optometry, Inc to communicate with me, as well as disclose personal information, over the phone or via the onpatient portal and/or e-mail. I give this permission understanding these forms of communication may be unencrypted. I am aware that there is some level of risk that third parties might be able to read unencrypted emails.

CONSENT FOR TREATMENT

✔️ I voluntarily give my permission to the optometrists of Vivid Visions Optometry, Inc to provide medical services to me. I understand by signing this form, I am authorizing them to treat me as long as I seek care from the optometrists of Vivid Visions Optometry, Inc or until I withdraw my consent in writing. I acknowledge that the practice of optometry is not an exact science. I acknowledge that no guarantees have been or can be made to me as a result of such procedures and treatments.
CONTACT LENSES ARE CLASSIFIED AS MEDICAL DEVICES BY THE FDA AND HAVE THE POTENTIAL TO HARM YOUR EYES AND/OR RESULT IN COMPLETE VISION LOSS. IT IS IMPORTANT THAT YOU UNDERSTAND AND FOLLOW ALL INSTRUCTIONS COMPLETELY AS THEY ARE WRITTEN.

At Vivid Visions Optometry, Inc, we carry the latest in contact lens technology, and specialize in the difficult-to-fit patients. In addition to soft contact lenses, we also fit astigmatism-correcting lenses, multifocal lenses, contacts for corneal diseases (like keratoconus) and post-surgical contact lenses. We are dedicated to your health and an enjoyable, comfortable contact lens experience.

Contact Lens Evaluation fees are necessary to a release a contact lens prescription and is in addition to the comprehensive/ general eye examination fee. All Contact Lens Evaluations will include precise measurements, analysis of your vision needs and recommendations specifically tailored for you. They may also include the use of diagnostic lenses if necessary by our doctors to ensure the proper fit of the lenses and good ocular health.

The Contact Lens Evaluation fee for contact lenses will range in price depending on the complexity of the fitting process.

A Contact Lens Prescription will be provided at the end of the fitting process only after all follow- ups are completed. The release of your contact lens prescription, good for one year from your initial fitting date, is conditional on you following the recommended care guidelines as described here and returning for any required evaluations to monitor your eye health and condition of your contact lenses.

✔️ I understand that the FDA considers contact lenses medical devices and that contact lens prescriptions expire every year. The FDA requires an annual contact lens evaluation, for which a separate fee is charged beyond the routine eye exam.

✔️ I have read and I understand the instructions on the care and use of my contact lenses. I understand that I must return to the doctor for a follow-up examination if instructed to do so within 30 days after my contact lenses have been dispensed to me. Additional charges will incur if the visits are missed and extend beyond the 30 days.

✔️ I have been informed of the necessity for yearly examinations to monitor my eye health and condition of my contact lenses. It is my understanding that improper use and inadequate care of contact lenses can cause eye irritation, infections, corneal injury and vision loss. I know that if I do not return to the Doctor as instructed or if I misuse my lenses, the Doctor, the opticians, and the contact lens manufacturer cannot be held responsible for any damage that may occur and

ADDITIONAL EXAMINATION FEES WILL APPLY.

✔️ I assign and authorize insurance payments to Vivid Visions Optometry, Inc to be used towards the contact lens evaluation fees.
Purpose of Today's Visit (select all that apply)*

Glasses PrescriptionEyewear PurchaseContact Lenses PrescriptionContact Lens PurchaseEye Emergency or Ocular Health EvaluationUndilated Eye Health Check - PUPIL DILATION REFUSAL - Acting under my own will and judgment, I fully understand the circumstances associated with refusing to have my eyes dilated. As a consequence, I understand that the doctor may not be able to detect cases in which the retina is diseased, physically compromised, or harboring cancerous growths. As such, early detection and diagnosis of certain eye conditions, along with timely and effective treatment, may not be possible. I accept all risks for the possibility of not detecting these eye conditions without pupillary dilation, and I understand that these conditions may result in permanent blindness, or even death.Dilated Eye Health Check - PUPIL DILATION CONSENT - I authorize the doctor and / or his ophthalmic assistants to administer dilating eye drops during the course of treatment. I understand that the Dilated Fundus Evaluation may have an additional fee and is not part of the routine eye exam. I understand that these eye drops are necessary to diagnose certain eye conditions. I further understand and acknowledge that I have been warned of the potential risks that dilating eye drops may have on my ability to drive and will take appropriate steps to reduce this risk by not driving immediately after my eyes have been dilated; or by wearing sunglasses while driving.Virtual or Zoom Consultation (complete BVD Questionnaire)BVD Evaluation for Prisms & Vision Therapy (complete BVD Questionnaire)BVD Annual Re-Evaluation for Prisms & Vision Therapy (complete BVD Questionnaire)LASIK ConsultationFollow-upOther
Signature

Clear
NOTICE OF PRIVACY PRACTICES
Should be Empty:

PATIENT PERSONAL INFORMATION

EMERGENCY CONTACT

RESPONSIBLE PARTY

VISION INSURANCE