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Microsoft word - 491c8287-6d5d-0823b4.doc

Patient Data Sheet
Patient Information
MR. MS. MRS. MISS (circle one) First Name _______________________ Last Name __________________________ M_____ Address__________________________________________________ City ______________________________ State ______ Zip_________ Sex M F Age ______ DOB____________ SS#_____________________ Hm Ph.#_____________________ Bus Ph.#____________________ Cell# __________________ Employer _______________________________ Occupation ______________________________ E-Mail Address _________________________________________________________________ Whom may we thank for referring you?_______________________________________________ Who is your current eye doctor?___________________________________Phone#____________ Has your current eye doctor ever suggested LASIK eye surgery to you? Y N Name _____________________ Relationship ________________ Phone#____________________ • How long have you been considering LASIK or another vision correction option? __________________________________________________________________________ • Have you been told in the past that you were a candidate for LASIK and if so, how long ago __________________________________________________________________________ • What prompted you to schedule your consultation with our practice? ___________________________________________________________________________ ___________________________________________________________________________ • What activities will you be able to more fully participate in after your vision is corrected? ___________________________________________________________________________ ___________________________________________________________________________ • What is most important to you in making a decision to have your vision surgically corrected? ___________________________________________________________________________ ___________________________________________________________________________ • What is your desired outcome from today’s visit? ____________________________________________________________________________ ____________________________________________________________________________ Patient Data Sheet
Assignment and Release
¾ Refractive procedures are elective and not generally covered by insurance. I understand that unless there is a contractual obligation or prior agreement if you should file my insurance or agree to any alternative form of payment including payment from any third party I am still ultimately responsible for and guarantee the payment of all fees owed. ¾ During a refractive consultation it may be necessary to dilate my eyes to confirm my candidacy. Dilating drops may blur vision for a length of time that varies from person to person. I authorize Dr. Updegraff and/or his associates to administer dilation drops during any of my consultation ¾ Should I choose to schedule surgery, I understand that I am responsible for a scheduling deposit ¾ In the event that I must cancel my surgical date, I understand that my scheduling deposit is refundable up to 48 hours prior to the scheduled procedure. ¾ I acknowledge that I have received your Patient Information Privacy Notice. ¾ I understand this is an initial consultation only to determine my candidacy for a refractive procedure. Unless I follow up with surgery or regular office visits no doctor patient relationship has been established and no information from this consult will be released to anyone. ___________________________________ _________________________ HEALTH HISTORY FORM
NAME: ______________________________________
DATE: _____________________
YES NO HEART ATTACKS/ ANGINA WITHIN LAST 2 YEARS NO PERMANENT DEFECT FROM ILLNESS, DISEASE OR INJURY NO DO YOU SMOKE_____PKS PER DAY_____ WK_____ MO _____ YES NO ARE YOU TAKING OR HAVE YOU TAKEN SABRIL?YES NO ARE YOU USING LATISSE? NO DO YOU DRINK _____# PER DAY_____WK _____ MO _____ HEIGHT____ WEIGHT ____
PLEASE LIST ALL MEDICATIONS YOU ARE TAKING AND THE DOSAGE:
ALLERGIES: ________________________________________________________________________________________
SURGICAL HISTORY (Please include Date and Type)
PROBLEMS WITH ANESTHESIA YES _____ NO _____
OCULAR HISTORY (HAVE YOU BEEN DIAGNOSED WITH ANY OF THE FOLLOWING IN THE PAST?)
NO CORNEA DISEASE _______________________________ NO GLAUCOMA ____________________________________ NO INJURY ________________________________________ YES NO IRITIS ___________________________ NO OTHER EYE DISORDERS _________________________ CATARACT SURGERY (date of surgery) RIGHT _________ RETINA SURGERY (Date of surgery) RIGHT ____________ FAMILY HISTORY (has anyone in your family (blood relative) has any of the following?) (NOTE RELATION TO PATIENT: F- Father M- Mother P-Paternal M- Maternal S- Sister B- Brother GF- Grandfather GM-Grandmother U- Uncle A- Aunt) YES NO GLAUCOMA ________________________YES NO CATARACTS ____________________ NO HEART PROBLEMS ____________________________________ NO DIABETIC RETINOPATHY ______________________ NO RETINAL DETACHMENT _______________________ YES NO RETINITIS PIGMENTOSA _______________ NO STROKE ______________________________________ NO OTHER GENERAL HEALTH PROBLEMS __________ PRIMARY CARE PHYSICIAN:
PATIENT SIGNATURE: ______________________________ CONTACT PHONE NUMBER: ____________________________
TECH/ DR. NAME:
DATE UPDATED/REVIEWED: _______________________
CHANGES IN MEDICAL HISTORY OR MEDICATIONS SINCE LAST VISIT: YES _______ NO ______ CHANGES THAT HAVE OCCURRED: ___________________________________________________________________________________ _______ ___________________________________________________________________________________________________

Source: http://www.lasik4me.com/pdf/patient-form.pdf

Microsoft word - riad-conclusions-adr_121019.docx

Impact of the proposed legislation on alternative dispute resolution (ADR) and online dispute resolution (ODR) on legal protection insurance RIAD evaluated whether the proposed legislation on alternative dispute resolution (ADR)1 and online dispute resolution (ODR)2 will have an impact on legal protection insurance and whether it will necessitate changes of national provisions regulating l

Copia di comunità viva speciale pasqua 2009.pub

Catechesi e Liturgia Animazione TRASMETTERE LA FEDE CELEBRANDO LA FESTA IN FAMIGLIA . Voglio riferirmi ancora qui all'esperienza del popolo ebraico, quella che quoti-dianamente vado facendo in Israele, dove per trasmettere la fede non ci sono catechi-smi, catechisti e nemmeno ore di religione. Come viene allora trasmessa la fede? In famiglia, non attraverso definizioni astratte,

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