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Medical History Form

Please fill this form out if you have already scheduled your eye examination with us.

Thank you!

Was your last exam at EyeCare Optical?
Please Specify what type of visual correction you currently use:
If you marked that you are a new contact lens wearer, please mark that you understand that contact class will be set up after exam. The charge for the 1 hour class is $40 which includes contact follow up with Dr. Zaporski:
I understand that I will have to set up a contact class which is $40
Not applicable
Please select if you have/had any of the following. Choose 1 or more:
Do you currently smoke?:
Yes
No
Are you currently pregnant?
Yes
No
We are performing Retinal Photography for all patients. The cost of this additional service is $39. Please note most insurances do not cover this additional charge.
Yes, I acknowledge the $39 photography fee.
No, I decline retinal photos.
When paying we prefer check, cash, or HSA cards. All other card will incur a 2% processing fee.
There will be a charge of $50 for a no show or cancellations will less than 24 notice
I understand that I will be charged $50 if I now show or cancel my appointment under 24 hours.

Notice Of Privacy Practice:

Right to notice as a patient: You have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), EyeCare Optical can use your protected health information for treatment, payment, and health care operations. Treatment–we may use or disclose your healthy information to a physician or other healthcare providers providing treatment to you. Payment–we may use and disclose your health information to obtain payment for services we provide you in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, evaluating provider performance, conducting training programs, accreditation, certification licensing or credentialing activities.

Your authorization: Most uses and disclosures that do not fall under treatment, payment, healthcare operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time. 

Emergency situations: In the event of your incapacity or emergency situation, we will disclose health information to a family member or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person’s involvement with your healthcare.

Marketing: We will not use your health information for marketing communications without your written authorization.

Required by law: We may also use or disclose your health information when we are required to do so by law. 

Appointment reminders: We may use or disclose your health information to provide you with appointment reminders via phone, email, or letter. 

*If you would like further information regarding privacy practices and HIPAA, please let a staff member know and we will provide you with a copy of that information.

By checking this box, I understand that I have been notified of EyeCare Optical's privacy practice.
I have read and understand the above policies regarding the Notice of Privacy Practice
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If you have any further questions, please fill out our Contact Form below:

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