AVC Intake & Medical History Patient Info

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AVC Intake & Medical History Responsible Party Info

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AVC Intake & Medical History Medical and Vision Plan Information

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  •  Yes
  •  No

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Financial Agreement

Payment for all professional services rendered is due at the time of service. If you have health insurance, it is your responsibility to ensure we have correct and current information for your insurance plan. It is also your responsibility to pay the copay at the time of service per our contract with your insurance plan. If you are not using health insurance,  payment for services rendered is required at the time of service.

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Notice of Privacy Policy

We keep a record of the health care services we provide to you. You may request a copy of your medical record in writing. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. You may request a copy of your medical record or get more information by contacting our practice. Our Notice of Privacy Practices is available at the reception desk and is posted in the clinic. The Notice describes in greater detail how your health information may be used or disclosed, and how you can access your information. You are entitled to a copy of this Notice and it is available at your request.

I acknowledge the Notice of Privacy Practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act.

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AVC Intake & Medical History COVID Questions

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  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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AVC Intake & Medical History Medical History

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AVC Intake & Medical History Current Eye Symptoms

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  •  Glare Sensitivity
  •  Headaches
  •  Light Sensitivity
  •  Tired Eyes
  •  Burning
  •  Dryness
  •  Excess Tearing/Watering
  •  Eyelid Swelling
  •  Eye Pain or Soreness
  •  Foreign Body Sensation
  •  Infection of Lid
  •  Itching
  •  Mucous Discharge
  •  Drooping Eyelid
  •  Redness
  •  Sandy or Gritty Feeling
  •  Blurred Vision Distance
  •  Distorted Vision (Halos)
  •  Double Vision
  •  Flashes
  •  Floater or Spots
  •  Fluctuating Vision
  •  Loss of Central Vision
  •  Loss of Side Vision
  •  Other
  •  None

AVC Intake & Medical History Eye History

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  •  Amblyopia (Lazy Eye)
  •  Infection of the Eye Lid
  •  Blindness
  •  Color Blindness
  •  Diabetic Retinopathy
  •  Dry Eye Syndrome
  •  Eye Injuries
  •  Glaucoma
  •  High Risk Medication
  •  Macular Degenration
  •  PVD (Vitreous Detachment)
  •  Retinal Detachment
  •  Crossed Eyes
  •  Keratoconus
  •  Corneal Disease
  •  Other
  •  None

AVC Intake & Medical History General Health Conditions

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  •  Fever, Weight Loss, Fatigue, etc.
  •  Ears, Nose, Throat
  •  Cardiovascular (High BP, etc.)
  •  Respiratory (Asthma)
  •  Gastrointestinal
  •  Kidney, Bladder
  •  Muscles, Bones, Joints
  •  Skin (Rash, Itching, etc)
  •  Neorological (Medical Sclerosis)
  •  Anxiety or Depression
  •  Thyroid, Diabetes
  •  Blood (Cholesterol, Anemia, etc.)
  •  Allergic, Immuno
  •  Pregnant
  •  Nursing
  •  Autoimmune Disease
  •  None
  •  Amblyopia (Lazy Eye)
  •  Blindness
  •  Cataract(s)
  •  Color Blindness
  •  Eye Tumors
  •  Glaucoma
  •  Glaucoma Suspect
  •  Macular Degeneration
  •  Retinal Detachment
  •  Strabismus (Eye Turn)
  •  Arthritis
  •  Cancer
  •  Diabetes
  •  Heart Disease
  •  High Blood Pressure
  •  Kidney Disease
  •  Lupus
  •  Stroke
  •  Thyroid Disease
  •  Autoimmune Disease
  •  Other
  •  None

AVC Intake & Medical History Social History

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  •  Not at all
  •  Occasional
  •  1 per day
  •  2-3 per day
  •  4+ per day
  •  Non-Tobacco User
  •  Current Tobacco User
  •  Light Tobacco User
  •  Moderate Tobacco User
  •  Heavy Tobacco User
  •  Past Tobacco User
  •  Yes
  •  No
  •  Yes
  •  No

AVC Intake & Medical History Spectacle/Contact Lens History

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  •  Glasses
  •  Contacts
  •  Contacts & Glasses
  •  None
  •  Soft Daily Wear
  •  Soft Disposable
  •  Ridgid
  •  Specialty Lenses
  •  Single Vision
  •  Bi-Focals
  •  Tri-Focals
  •  Progressives
  •  Safety
  •  Office/Computer
  •  None
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