Patient Initake Form

Patient Intake Form

CONTACT LENS FITTING
Patient Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Person

First NameLast Name
Emergency Contact Person Phone
Please enter a valid phone number.
Relationship
Do you have any medical conditions that the clinic should be aware of? If yes, please indicate and explain it below:
HOW DID YOU HEAR ABOUT US?

If yes, please specify:
UPLOAD GLASSES PRESCRIPTION:

Cancelof
Thank you for providing this information. It will help us understand your eye care history better.
UPLOAD CONTACT LENS PRESCRIPTION:

Cancelof
UPLOAD MEDICAL HISTORY:

Cancelof

Acknowledgment and Waiver
ACKNOWLEDGMENT AND WAIVER FORM

I, hereby acknowledge and understand that Cosmic Contact Lenses ("the Company") shall not be responsible for any medical health problems that may arise now or in the future due to noncompliance or negligence on my part. I voluntarily assume all risks associated with the use of contact lenses and understand that:

1. Compliance with Instructions: I will comply with all instructions, guidelines, and recommendations provided by the Company or its authorized representatives regarding the proper usage, cleaning, and maintenance of the contact lenses.

2. Professional Ocular Examination: I acknowledge that prior to using contact lenses, I have received a professional ocular examination from a licensed eye care provider and have obtained a valid prescription for contact lenses.

3. Regular Eye Health Checks: I understand the importance of regular eye health checks and will schedule and attend periodic check-ups with a licensed eye care provider as recommended.

4. Proper Usage: I will only use the contact lenses as prescribed and directed by the licensed eye care provider, and will not share or use lenses that have been prescribed for another person.

5. Hygiene and Safety: I will maintain good hygiene practices such as washing hands before handling contact lenses, using recommended contact lens solutions, and properly storing the lenses to prevent contamination.

6. Reporting Issues: I will promptly report any discomfort, pain, redness, swelling, or adverse reactions related to the use of contact lenses to both the Company and my licensed eye care provider.

7. Indemnification: I agree to indemnify, defend, and hold harmless Cosmic Contact Lenses, its affiliates, employees, agents, and authorized representatives from any claims, damages, liabilities, costs, and expenses that may arise from my noncompliance or negligence.

By signing below, I recognize that I have read, understood, and agreed to the terms and conditions outlined in this Acknowledgment and Waiver Form. I further acknowledge that this waiver shall be binding upon me, my heirs, representatives, and assigns.
**Notice of Privacy Practices**

*This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.*

**Privacy Notice**

*This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.*

**OUR PLEDGE**

We understand that medical information about you is personal. We are committed to protecting your privacy and will follow all laws regarding the confidentiality of your medical information.

**Cosmic Contact Lenses, Cosmic Co., Lily Quinn Optix, and SureSight Optical**
**USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS**

We may use and disclose your medical information for treatment, payment, and healthcare operations. For example, we may use your information to provide you with medical services, process payments for those services, or conduct quality assurance activities.

**SECURITY SAFEGUARDS**

We maintain appropriate safeguards to ensure the security and confidentiality of your medical information.

**YOUR RIGHTS**

You have the right to request restrictions on how your information is used and disclosed, receive confidential communications, inspect and obtain a copy of your medical records, request amendments to your records, and receive an accounting of disclosures.
Date

MonthDayYear
Date
Signature

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Patient Intake Form

Patient Information

Acknowledgment and Waiver