Patient Intake Form

Health Questionnaire and Dilation

Bagga Optometry
Name*
Date of Birth*

MonthDayYear
Date
ELECTRONIC HEALTH QUESTIONNAIRE*

By checking this box, I attest that I have completed the electronic patient health questionnaire and all the information on the form is true and accurate to the best of my knowledge.
DILATION

Our office dilates all patients as part of a comprehensive eye examination. Dilating drops enlarge the pupil of the eye to allow the doctor to get a better view of the inside of your eye and properly assess the health. Without dilation, some ocular diseases cannot be detected. Side effects may include, but are not limited to, blurred vision for 4-6 hours and light sensitivity. Because driving may be difficult immediately after dilation, it is ideal to make arrangements to not drive yourself. Adverse reactions, such as acute angle closure glaucoma, may be triggered by dilating drops. This is extremely rare and treatable with immediate medical attention.
Please check one of the boxes below:*

I can be dilated today and understand the possible side effects.I DECLINE the dilation portion of the exam and will not hold Dr. Bagga responsible.
Signature*

Clear
Date

MonthDayYear
Date

Acknowledgement of Policies

Bagga Optometry
Copayment: It is the patient’s responsibility to pay their insurance copay requirements and/or examination fees at the time of service. Payments can be made via Credit Card or Cash.

Assignment of Insurance Benefits: I authorize Dr. Bagga to bill my insurance for services rendered and to release medical information related to those services as necessary. Under certain circumstances, unbeknown in advance to Dr. Bagga, claims can be denied. I understand that I am financially responsible for all charges whether or not paid by insurance.

Authorization of Communication: I authorize Dr. Bagga to contact me for the purposes of verifying and scheduling appointments.

Contact Lens Fittings: A contact lens fitting is required to provide you with a contact lens prescription at the end of the examination. The fitting process includes a health assessment of your eye to ensure that you are a good candidate for contact lens wear and an evaluation of the fit of the contact lens on your eye. The fitting process also includes any diagnostic trial lenses and follow up care required to get the proper contact lens prescription. First time contact lens wearers will also complete a training session with our technician. All follow up visits must be made within 60 days of the initial contact lens examination. A contact lens fitting may be subject to an additional fee or copay due to the additional services that are added to the exam and is due in full at the time of the fitting.

Acknowledgement of Privacy Practices: Dr. Bagga is required by law to maintain the privacy of your protected health information under the Health Insurance Portability and Accountability Act (HIPAA). Patient information is confidential except as is necessary to provide services or to ensure all administrative matters related to your care are handled appropriately. Most uses and disclosures that do not fall under treatment, payment, and health care operations will require your written authorization. I, the patient, acknowledge that I have received and reviewed the Notice of Privacy Practices document.
Signature*

Clear
Date

MonthDayYear
Date
If you have signed this form as a legally authorized representative of the Patient, please print your name and relationship to the Patient below.
Name of Representative
Relationship to Patient
Should be Empty:

Health Questionnaire and Dilation

Acknowledgement of Policies