Patient Paper Work

IMPORTANT: This questionnaire is to be reviewed at each appointment. Please answer all questions

Insurance Information

Medical Information

Self/Family History (Under "Relation", write "Self" for yourself or indicate which family member)

Personal Eye Information

Are you satisfied with you:

Headaches

REFERRAL ACKNOWLEDGEMENT

A referral for further evaluation/treatment may be made when a potential problem exists that could have significant consequences if not appropriately addressed. Some consequences can lead to blindness or be a threat to your health. While we use the utmost care, we cannot absolutely guarantee that all referral letters, phone calls, or faxes are received. We make the referral in good faith and with your acknowledgment. In order to safeguard your well-being, it is incumbent upon you to contact us if you have not obtained your referral appointment in a timely fashion. The ultimate decision/responsibility to keep the appointment is always yours.

RETURN VISIT ACKNOWLEDGMENT

A return visit to our office to further evaluate, monitor, or treat a present condition is made in good faith Without further follow-up visits, some conditions may have consequences that could lead to blindness or be a threat to your health, When appointments made for further check-ups are not kept, the responsibility for the condition becomes yours.

EYEWEAR SAFETY DISCLOSURE

Whether for dress or safety eyewear you have a choice between polycarbonate or plastic lens materials. From strictly a protective basis (i.c. foreign body ocular penetration from the lens material), the type of material that provides the greatest benefit is polycarbonate. It is not a function of simply wearing polycarbonate lenses; thus, if you have any situations where you feel at an increased risk of sustaining an eye injury, please let us know. In any event, the ultimate decision to choose protective polycarbonate material lenses is always yours.

OFFICE POLICY

a. Progressive lenses can be substituted with a pair of conventional trifocal or bifocal lenses at no additional cost to youl

b. Trifocal lenses can be substituted with a pair of conventional bifocal lenses at no addition cost.

c. Bifocal lenses can be substituted with a pair of single vision distance or near lenses.

J. Frames/spectacle lenses lose their ability to withstand the pressures of adjustments/repairs with time. While we use the utmost care, we are not responsible for any damages incurred during the process.

K. Scratch resistant lens coatings are just that, resistant, and not scratch-proof,

FINANCIAL RESPONSIBILITY

Insurance is billed, and in most cases, as a courtesy to the patient by Dr. Adhikari’s office. This office cannot accept responsibility for collecting insurance claims or for negotiating a settlement on a disputed claim. The undersigned authorizes direct payment to Dr. Adhikari, with any insurance benefits otherwise payable to the undersigned, for Dr. Adhikari’s services. It is understood by the undersigned that he/she is financially responsible for charges not covered by the payment that Dr.Adhikari receives from the insurance company. Verification for eligibility of benefits is not a guarantee of payment.

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

I authorize the release of any medical or other information necessary to process this transaction. 1 also authorize my insurance benefits to be paid directly to Dr. Adhikari. | understand that if in the event my insurance carrier pays less than the actual bill forthe services that have been provided to me, [ agree to be responsible for payment of all services and/or materials rendered on my nbehalf and/or my dependent (s). | have read and understand the content of these two pages.