The Optical Experience Intake Form

1

DATE

Date

2

FULL NAME

3

PREFERRED NAME

4

Date of Birth

Date

5

AGE

6

HOME ADDRESS

7

CITY

8

STATE

9

ZIP CODE

10

PHONE NUMBER (PRIMARY)

11

PHONE NUMBER (SECONDARY)

12

OCCUPATION

13

EMAIL ADDRESS

example@example.com

14

Email Subscribe

15

NAME

16

RELATIONSHIP

17

- PHONE NUMBER

18

Do you have a vision plan?

19

VISION PLAN PROVIDER

20

MEMBER ID

21

EMPLOYER

22

REASON FOR TODAY'S VISIT?

23

Date of last exam( can be around date doesn't have to be specific)?

Date

24

PREVIOUS EYE CARE PROVIDER

25

Do you wear eyeglasses?

26

Do you wear contact lenses?

27

Do you currently have issues with your current glasses?

28

IF YES, PLEASE DESCRIBE.

29

Have you had any eye injuries?

30

IF YES, PLEASE DESCRIBE.

31

Have you had any eye surgeries?

32

IF YES PLEASE DESCRIBE.

34

Do you have any current health conditions?

35

IF YES PLEASE LIST

36

Are you currently taking any medications?

37

IF YES, PLEASE LIST WITH DOSAGE.

38

Do you have any allergies?

39

IF YES, PLEASE LIST.

41

HIPAA COMPLIANCE

Notice of Privacy Practice

I ACKNOWLEDGE THAT I HAVE RECEIVED AND REVIEWED THE NOTICE OF PRIVACY PRACTICES FOR THE OPTICAL EXPERIENCE. IF YOU WOULD LIKE A COPY EMAILED TO YOU FOR YOUR RECORDS PLEASE LET US KNOW.

42

SIGNATURE

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43

INSURANCE ASSIGNMENT AND PAYMENT AUTHORIZATION

I AUTHORIZE ABITA EYE GROUP/THE OPTICAL EXPERIENCE TO FILE CLAIMS WITH MY INSURANCE PROVIDER ON MY BEHALF FOR EYE CARE SERVICES RENDERED AT THE OPTICAL EXPERIENCE. I ALSO AUTHORIZE PAYMENT OF BENEFITS DIRECTLY TO ABITA EYE GROUP/THE OPTICAL EXPERIENCE FOR SERVICES PROVIDED.

44

SIGNATURE

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45

Date

46

How did you hear about us?

47

THANK YOU

WE ARE DELIGHTED TO HAVE YOU AS A VALUED CLIENT. OUR GOAL IS TO PROVIDE YOU WITH A CURATED VISION EXPERIENCE THAT PERFECTLY FITS YOUR LIFESTYLE AND NEEDS. IMPORTANT INFORMATION AND DISCLAIMER PRESCRIPTION RIGHTS: YOU ARE ENTITLED TO A COPY OF YOUR PRESCRIPTION ONCE THE EXAM HAS BEEN COMPLETED AND PAID FOR IN FULL. PAYMENT POLICY: PAYMENT FOR YOUR EXAM IS DUE AT THE TIME OF YOUR APPOINTMENT. GLASSES CAN BE PAID FOR EITHER IN FULL AT THE TIME OF ORDER OR THROUGH OUR AVAILABLE PAYMENT PLAN OPTIONS. ALL SALES FINAL: PLEASE NOTE THAT ALL EYEWEAR SALES ARE FINAL. HOWEVER, ALL GLASSES COME WITH ONE FREE REMAKE DUE TO PRESCRIPTION CHANGES. WE DO NOT OFFER RESTYLES DUE TO OUR EXTENSIVE FITTING PROCESSES. WE DO HONOR NON-ADAPTS WITHIN 90 DAYS, AND ALL PRESCRIPTION CHANGES MUST BE MADE WITHIN 90 DAYS OF THE ORIGINAL EXAM. EXAM DURATION: THE EXAM PROCESS TYPICALLY TAKES 1.5 HOURS. IF YOU ARE UNABLE TO STAY FOR THE ENTIRE DURATION, WE ARE HAPPY TO RESCHEDULE YOUR APPOINTMENT TO A MORE CONVENIENT TIME. FOLLOW-UP POLICY: ANY FOLLOW-UPS NOT COMPLETED WITHIN THE ALLOWED TIME FRAME WILL BE SUBJECT TO A CHARGE FOR A NEW EXAM. REQUESTING RECORDS: IF YOU NEED A COPY OF YOUR RECORDS. YOU CAN REQUEST THEM BY EMAILING US AT DESTYNEE@MYOPTICALEXP.COM OR BY CALLING US AT 561-401-0902.