VVO Patient Registration Form

Vivid Visions Optometry, Inc. is an independent optometry practice located at 27201 Tourney Rd. Suite 100, Valencia, CA 91355, inside the Valencia Executive Plaza. We provide advanced, personalized eye care in accordance with California optometry law.

Our services include comprehensive eye exams, contact lens fittings, corneal and retinal evaluations, glaucoma and macular assessments, and advanced testing for dry eye disease and other ocular conditions.

We also specialize in binocular vision and neuro-visual care for headaches, migraines, concussions, and eye misalignments, as well as sports vision evaluations, specialized prism fittings, and personalized vision therapy programs. Using multiple VR-based eye tracking technologies and advanced imaging, we are able to detect, document, and track subtle changes in eye health with precision.

In addition, we offer a wide selection of frames, lenses, and specialty contact lenses to fit every style and lifestyle need.
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
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Address*

Street Address

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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 guardian/parent 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 visionVISUAL CLARITY: Floaters or shadows in 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
Based on the symptoms you've selected, you may be showing signs of Binocular Vision Dysfunction (BVD).

Binocular Vision Dysfunction (BVD) occurs when the eyes struggle to work together as a team, even if each eye sees clearly on its own. This misalignment can lead to symptoms like headaches, dizziness, eye strain, anxiety, difficulty reading, light sensitivity, and more.

BVD is often missed during routine eye exams because those exams typically check each eye individually and may not include the specialized testing needed to evaluate how both eyes coordinate together.

At Vivid Visions Optometry, Inc., we use a combination of manual tests, virtual reality (VR) technology, and eye-tracking equipment to measure your eye alignment, focusing ability, tracking skills, and how your brain processes visual input. These tools allow us to detect subtle dysfunctions that standard exams may overlook—so we can accurately diagnose and treat the root cause of your symptoms.

✔️ I understand that Binocular Vision Dysfunction (BVD) is a condition that requires a separate Comprehensive Binocular Vision Evaluation, which must be scheduled in addition to a routine or comprehensive dilated eye exam.

✔️ I understand that this specialty evaluation is not covered by insurance, and Vivid Visions Optometry, Inc. does not accept insurance payments for BVD evaluations or follow-up visits.

✔️ I understand that prism prescriptions and personalized vision therapy treatment plans can only be discussed during a scheduled BVD evaluation or follow-up appointments—not during a routine eye exam.

✔️ I understand there is a separate fee for the initial BVD evaluation and for each follow-up appointment.

✔️ I understand that multiple follow-ups may be required to fine-tune my prism prescription and treat the underlying issue, as many people with BVD have been unknowingly compensating for years.

✔️ I understand that a follow-up is required 4 weeks after receiving a new prescription to evaluate whether a change in the prescription is necessary.

✔️ I understand that if no changes are needed during the 4-week follow-up, I will be monitored every 3–6 months depending on symptoms and progress.

✔️ I understand that if follow-up appointments are not scheduled and I have not been seen for a follow-up within 6 months, I will need to complete a BVD re-evaluation before continuing treatment or updating prescriptions.

✔️ I understand that the goal of the BVD evaluation is to determine how both eyes work together as a team, unlike routine exams which test one eye at a time.

✔️ I understand that once a misalignment is detected, I may need multiple prescriptions and a period of time for symptoms to improve, depending on the severity and how long the issue has been present.

✔️ I understand that the degree of misalignment can vary at different distances, which means I may need different prescriptions for different tasks (e.g., reading, computer use, or driving).
Please select all ocular and medical conditions that apply to you.*

NO KNOWN MEDICAL CONDITIONSGENERAL: CancerENDOCRINE: DiabetesENDOCRINE: Pre-DiabetesENDOCRINE: Thyroid issuesCARDIOVASCULAR: High blood pressureCARDIOVASCULAR: High cholesterolCARDIOVASCULAR: History of strokeCARDIOVASCULAR: POTS (Postural Orthostatic Tachycardia Syndrome)EYE: History of lazy eye or strabismus, patching, or vision therapyEYE: GlaucomaEYE: Dry Eye SyndromeEYE: KeratoconusEYE: Macular degenerationEYE: Diabetic retinopathyEYE: 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 involves placing two eye drops to enlarge the pupil, allowing a full view of the internal structures of the eye to check for signs of disease.

Without dilation:
- Eye diseases such as glaucoma, macular degeneration, and diabetic retinopathy may go undetected.
- Serious conditions such as retinal tears, detachments, or cancerous growths may be missed.
- Early detection, accurate diagnosis, and timely treatment may not be possible.
✔️ I understand the importance of dilation and that refusing dilation may put me at risk for missed or delayed diagnoses, progression of eye disease, or permanent vision loss.

✔️ I accept full responsibility for any risks or consequences if I decline dilation when recommended by my doctor.
RETINAL FUNDUS PHOTOGRAPHY & RETINAL/OPTIC NERVE OCT

Based on your symptoms and/or ocular/medical history, performing Retinal Fundus Photography and Retinal/Optic Nerve OCT is strongly recommended by our doctor. These imaging tests provide high-resolution documentation of the retina, macula, and optic nerve to detect, measure, and monitor signs of eye disease.

Without these tests:
- Important findings may be missed.
- Diagnoses may not be accurate or complete.
- There is no reliable way to measure or track changes in eye health over time.
These tests are essential for early detection, accurate documentation, and ongoing monitoring of conditions such as glaucoma, macular degeneration, diabetic retinopathy, and other retinal or optic nerve disorders.

✔️ I understand the importance of Retinal Fundus Photography and Retinal/Optic Nerve OCT.

✔️ I understand that declining these tests may result in missed or delayed diagnoses, lack of proper documentation, and inability to track changes over time.

✔️ I understand that there is an additional fee for these tests and that Vivid Visions Optometry, Inc. does not bill insurance for them. I acknowledge that these services will most likely be an out-of-pocket expense.

✔️ I accept full responsibility for the risks involved if my doctor recommends these tests and I choose to decline.
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 lack of 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 must be paid at the time services and/or materials are rendered.

✔️ I understand that there are NO refunds for services that have already been provided, including evaluations, procedures, or follow-up care.

ACKNOWLEDGEMENT OF CANCELLATION & NO-SHOW POLICY

By scheduling an appointment with Vivid Visions Optometry, Inc., I acknowledge and agree to the following terms:

✔️ I understand that Vivid Visions Optometry, Inc. requires at least 48 hours' notice to cancel or reschedule an appointment.

✔️ I understand that cancellations made less than 48 hours in advance and all no-shows will result in a cancellation fee ranging from $50 to $200, depending on the length and type of the scheduled exam.

✔️ I understand that a valid credit card must be placed on hold when scheduling appointments. This card will be securely kept on file and may be charged if I fail to adhere to the cancellation and no-show policy.

✔️ I understand that no further appointments will be scheduled until any outstanding cancellation or no-show fees are paid in full.

✔️ I understand that after two or more no-shows, I will be considered a Walk-In patient only. I agree to come in without a scheduled appointment and wait until an availability opens that day for the doctor to see me. Scheduled appointment privileges may be reinstated at the discretion of the clinic.

✔️ I acknowledge that this policy is necessary to ensure that all patients have access to timely services.

✔️ I accept full responsibility for adhering to this 48-hour cancellation and no-show policy.
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.

✔️ I understand that from time to time patients may be offered the opportunity to share their experiences, testimonials, or reviews on video or in writing. If I choose to participate, I give Vivid Visions Optometry, Inc. permission to record, publish, and share these testimonials, including my image, likeness, voice, statements, and any medical information I choose to disclose, on social media platforms, websites, and other media outlets worldwide. I understand that participation is completely voluntary, no compensation will be provided, and I may decline at any time.

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)*

PURCHASE: EyewearPURCHASE: Contact LensesEXAM & PRESCRIPTION: GlassesEXAM & PRESCRIPTION: Contact LensesEXAM: Undilated 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.EXAM: 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.EXAM: Eye Emergency or Ocular HealthEXAM: BVD Evaluation for Prisms & Vision Therapy (complete BVD Questionnaire)EXAM: BVD Annual Re-Evaluation for Prisms & Vision Therapy (complete BVD Questionnaire)EXAM: LASIK ConsultationEXAM: Follow-upADDITIONAL TEST: Retinal Fundus Photo (Retinal Camera)ADDITIONAL TEST: Visual Field TestingADDITIONAL TEST: Retinal Scan (OCT)ADDITIONAL TEST: Optic Nerve Scan (OCT)ADDITIONAL TEST: Corneal Scan (Topography)VIRTUAL: Consultation (complete BVD Questionnaire)Other
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NOTICE OF PRIVACY PRACTICES
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PATIENT PERSONAL INFORMATION

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RESPONSIBLE PARTY

VISION INSURANCE